490108000-5-9-2023-21-AS-VBEI-CRNRQZ-20230509131421

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 05/09/2023
Date Signed: 05/09/2023 01:14:53 PM

Document Has Been Signed on 05/09/2023 01:14 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	MC HUGH CARE HOME		FACILITY NUMBER:	490108000
ADMINISTRATOR:	DIZON, TIFFANY		FACILITY TYPE:	740
ADDRESS:	1000 GORDON LANE		TELEPHONE:	(707) 545-8213
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	15	CENSUS: 10	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Myla Rublico		TIME COMPLETED:	01:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff, Myla Rublico. Administrator, Nick Aquino was unavailable during inspection. LPA initiated a tour of the facility around 8:40am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents room were furnished per regulation. Bathroom used by residents had a urine smell, soiled clothing and was not clean and sanitary including debris on the floor and the sink being visually dirty. Facility staff cleaned bathroom during this inspection. Water temperature in bathroom used by residents measured at 144 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. Facility staff turned down water heater during this inspection. Walls and doorways in facility appeared dirty and items were being stored outside including soiled mattresses. Extra hygiene products and linens were available. Cleaning supplies are stored in the locked laundry room. Facility has at least two days of perishable and one week of non-perishable foods. Not all vegetables in refrigerator were of quality and refrigerator being used to store perishable foods was not clean. Medications were centrally stored in an unlocked medication cart. LPA reminded staff that the medication cart must be locked when left unsupervised. Medications for the evening had already been poured. LPA instructed staff that pre-pouring medication was not allowed and medication must stay in it's original container. Facility has emergency food and water supplies. Fire extinguisher was last serviced July 2022. Smoke detectors located throughout the facility as well as the Carbon Monoxide detector were tested and operational during inspection. Facility has not conducted a emergency disaster drill in the last three months. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because areas of the facility were visibly dirty, smelled of urine along with debris being stored in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Facilty staff cleaned the bathroom during LPA inspection. Facility agrees to clean doorways and walls that are visibly dirty and to remove all debris, including but not limited to mattresses, by POC due date 5/10/2023. LPA will return to facility to confirm completion.

Type A

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the water in temperature in the resident's bathroom being above the range allowed per regulation which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Facility staff turned down water heater during inspection. Facility will test water to ensure it is within regulation no later than POC due date 5/10/2023. LPA will return to facility to confirm completion.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by not locking the medication cart when left unsupervised, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2023
	Plan of Correction
1 2 3 4	Facility staff locked cart per LPA's instruction and confirmed that cart will be locked when left unsupervised. Deficiency is cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2023 01:14 PM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 staff not having proof of a First Aid and CPR Certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Facility agrees to maintain staff files in this facility including proof of First Aid and CPR Certificates by POC due date, 5/12/2023. LPA will return to review files.

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 staff not having staff files available at this facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Facility agrees to maintain staff files in this facility by POC due date, 5/12/2023. LPA will return to review files.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having proof that Administrator has an active Administrator Certificate which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Facility agrees to provide an update regarding the status of the Administrator's certification by 5/12/2023.

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 9 out of 10 residents not having an updated reappraisal which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Administrator to complete reappraisals for noted residents by POC due date, 5/12/2023. LPA will return to confirm completion.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 out of 10 residents not having a signed Admission Agreement which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Administrator must sign Admission Agreement and have resident or their responsible party sign agreement no later than 5/12/2023. LPA will return to confirm completion.

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having all perishable food being of good quality which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Facility agrees to go through all refrigerators and remove any and all foods that do not meet regulation by POC due date, 5/12/2023. LPA will return to confirm completion.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(23)

General Food Service Requirements

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having food not labeled and stored per regulation including but not limited to food being stored in foil and not completely covered, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Facility agrees to go through all refrigerators and repackage foods and label them per regulation by POC due date, 5/12/2023. LPA will return to confirm completion.

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by a refrigerator that stores perishable foods appeared dirty and unsanitary which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Facility agrees to clean refrigerators by POC due date, 5/12/2023. LPA will return to confirm completion.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the evening medications already poured and being stored in a separate container, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Facility will stop pre-pouring medications immediately and submit self-certification that medication will be stored in it's original container per regulation by POC due date 5/12/2023.

Type B

Section Cited

CCR

87465(h)(6)

87465 (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining a Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/12/2023
	Plan of Correction
1 2 3 4	Facility to find or complete the Centrally Stored Medication Log by POC due date, 5/12/2023. LPA will return to review.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

Page: 8 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
	VISIT DATE: 05/09/2023

NARRATIVE

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Continued from LIC809

Ten resident files were reviewed. Nine of ten residents do not have an updated reappraisal. Staff files were unavailable including proof of First Aid and CPR. Administrator Certificate for Administrator, Nick Aquino was unavailable and is not listed on the Department's Active or Pending Administrator Certificate list. LPA was unable to review medications because the Centrally Stored Medication Log was not available and per conversation with staff, was not bing maintained.

Licensee/Administrator to submit updates of the following documents by 6/09/2023:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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