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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804161
Report Date: 10/10/2024
Date Signed: 10/10/2024 02:35:20 PM

Document Has Been Signed on 10/10/2024 02:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VISTA PRADOFACILITY NUMBER:
486804161
ADMINISTRATOR/
DIRECTOR:		CHO, LINDAFACILITY TYPE:
740
ADDRESS:105 POWER DRIVETELEPHONE:
(707) 643-7617
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 68CENSUS: 43DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Veronica De-Leon (Assisted Living Director)TIME VISIT/
INSPECTION COMPLETED:
02:49 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting Required 1 Year inspection and met with Veronica De-Leon (Assisted Living Director). Annual fees are current. Contact information was reviewed. Required postings were observed. There are residents with a diagnosis of dementia and receiving hospice services.

LPA/Staff toured the buildings and grounds were found to be of a comfortable temperature, clean, in good repair and well organized including; living room, mobile kitchen, dining room; bathrooms; and laundry room, where walkways and exits were unobstructed. Water temperature measured 106.3 (room #3), 105.4 (room #6), 105.4 (room #9), 103.8 (room #20), 111.4 (room #23), 104.7 (room #15), 109.8 (room #31) and 112.1 (room #33) which a couple of them were not within regulation between 105 and 120 degrees F at faucets accessible to residents. Bathrooms have required grab bars and skid mats. Resident's rooms that have a sign of "No smoking-oxygen in use" have reports of notification to the fire departments on file. However, resident's bedroom (#3, #9, #15, #23 and #33) needs garbage cans to have a tight-fitting cover lids to prevent the transmission of any communicable disease or odor (technical violation issued). Resident room #15 needs a chair (technical advisory issued). Resident room #33 needed toilet paper (technical violation issued). Emergency lighting was observed. LPA pulled several cords in resident's rooms, which were found operational by alerting staff and staff responded within two to three minutes in average. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Modified diets prescribed by doctor were posted on kitchen refrigerators to alert staff of special food needs. Toxins are stored in a locked storage closet.
Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VISTA PRADO
FACILITY NUMBER: 486804161
VISIT DATE: 10/10/2024
NARRATIVE
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Continued from LIC809...

Fire extinguishers were charged and service as of September 2024. Facility has fire sprinklers throughout and wired smoke detectors that are serviced yearly by outside company. Last fire inspection report dated 8/8/24 was found within compliance. Disaster and Fire Drills are conducted, last drill was on 9/19/2024. Carbon monoxide detectors were tested and operational. Medication is centrally stored and locked. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. The facility has auditory system and 15 second delayed egress. There are surveillance cameras installed in common areas and two outside, facility understands surveillance cameras may not violate residents privacy. Residents were observed engaged in activities. Activity and menu calendar was observed.

LPA initiated file review at approximately 10:30AM, LPA reviewed 10 resident records and 5 staff files. Residents have updated medical assessments. However, two out of ten resident's (R1 & R2) care plans has not been updated within the last 12 months as indicated per regulation. Four out of five staff (S1, S2, S3 & S4) do not have a current CPR/1st aid certificate and do not have complete required training hours as stated per regulation. Administrator's certificate for Linda Cho #6003642740 expires 4/18/2025. Medication and medication records were reviewed.

Facility will submit updates of the following to CCL by 10/31/2024: LIC 500- Personnel Report, LIC 308- Designation of Responsibility and Current certificate of liability insurance.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with Assisted Living Director and copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/10/2024 02:35 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/10/2024 at 01:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VISTA PRADO
FACILITY NUMBER: 486804161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Director observation, interview and record review, the licensee did not comply with the section cited above in two out of eight faucets used by residents in care that measured less than 105 degree F, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The Director agrees to adjust water heater temperature, start a log of water temperature for seven days, then the facility will send to CCL with form LIC9098 by POC due date to clear deficiency.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Director observation, interview and record review, the licensee did not comply with the section cited above in four out of four staff have not completed CPR training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The Director agrees to have staff complete CPR/1st aid training and send to CCL with form LIC9098 by POC due date to clear deficiency.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2024 02:35 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 10/10/2024 at 01:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VISTA PRADO
FACILITY NUMBER: 486804161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in four out of four staff do not have additional training 20 hours completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The Director agrees to have staff complete training and send to CCL with form LIC9098 by POC due date to clear deficiency.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Director observation, interview and record review, the licensee did not comply with the section cited above in two out of two residents who did not have their care plan updated which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The Director agrees to have complete care plans for residents and send to CCL with form LIC9098 by POC due date to clear deficiency.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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