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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490106870
Report Date: 08/29/2023
Date Signed: 08/29/2023 10:45:27 AM


Document Has Been Signed on 08/29/2023 10:45 AM - 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:ALL SEASONS RESIDENTIAL CARE HOMEFACILITY NUMBER:
490106870
ADMINISTRATOR:GEORGE AND LISA MELOFACILITY TYPE:
740
ADDRESS:5509 VOLKERTS ROADTELEPHONE:
(707) 829-8109
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 5DATE:
08/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Lisa Melo (Licensee)TIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee, Lisa Melo. Required postings were observed.

LPA/Licensee initiated a tour of the facility around 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents rooms were furnished per regulation. Extra hygiene products and linens were available. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Hot water temperature in bathrooms used by residents measured at 106.3, 105.4 and 105.2 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Fire extinguisher was last serviced October 2022. Smoke detectors and carbon monoxide detector in the hallway was tested and properly working. Last disaster drill conducted on 8/7/23. Working auditory alarms are placed on all exits. Disinfectants and cleaning solutions were stored inaccessible to residents. Administrator Certificate for Lisa Melo, 6022235740, expires on 11/16/2024. Medications were reviewed, centrally stored and locked.

LPA initiated file review at 10:00 am. LPA reviewed five residents files and three staff files. Two out of five residents (R1 & R3) files does not have a current medical assessment and care plans were not signed by their responsible party within the last 12 months. Staff records have current First Aid/CPR certificates and additional 20 hours of required training. Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Copy of Liability Insurance.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
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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Document Has Been Signed on 08/29/2023 10:45 AM - It Cannot Be Edited

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: ALL SEASONS RESIDENTIAL CARE HOME
FACILITY NUMBER: 490106870

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in two out of five medical assessments LIC602s were not updated at medical appointments within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee agreed to obtain updated medical assessments for noted residents (R1 & R3) by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2023
LIC809 (FAS) - (06/04)
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