490108000-7-2-2024-21-AS-MCUA-D6SUY2-20240702155914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490108000
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:59:30 PM

Document Has Been Signed on 07/02/2024 03:59 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:	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: 11	DATE:	07/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Nick Aquino (acting Administrator)		TIME COMPLETED:	04:14 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) Cuadra arrived unannounced to conduct an Annual Inspection and met with staff Rodrigo Gallardo. Acting Administrator, Nick Aquino arrived later. LPA/staff initiated a tour of the facility at 1:30 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Water temperature in resident bathrooms measured at 106.9, 105.1 and 106.6 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected May, 2024. Smoke alarms and carbon monoxide detectors were found operational. According to acting administrator, there are no disaster drill been conducted during this year (technical violation had been issued). Facility has a fire pull system. The last fire department visit was conducted on June 2024. Resident rooms were furnished per regulation. At approximate 1:45pm LPA/acting administrator observed spider webs in resident's rooms (room #3 & room #2) and common areas. Window screen on room #3 needs to be replaced. All garbage cans do need to have a lid cover. Two out of three bathrooms were observed dirty and needing minor repairs on walls. At approximate 1:50pm LPA/acting administrator observed hallway closet where toxins are stored was unlocked during inspection. Staff immediately locked the laundry room area. Technical violation will be issued. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 8

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: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
	VISIT DATE: 07/02/2024

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
26
27
28
29
30
31
32

Continued from LIC809...
File review was initiated at 2:00 pm. Two staff files and five resident files were reviewed. One out of two staff do not have required First Aid and CPR certificates on premises (Technical violation was issued). Three out of five resident's care plan had not been updated within the last 12 months. During file review, LPA noticed resident (R1) was sent to the emergency room on May 2024. However, the Department was not notified about incident. LPA/acting administrator had a discussion regarding reporting requirements (technical violation was issued). Medications and medication records were reviewed.

On 6/28/23, The Department held an informal meeting in the Santa Rosa Regional Office with acting Administrator, Nicanor Aquino and Licensee Angelita Aquino to address concerns regarding administrator certification for this facility and the Licensee's other facility (AA Best Care 496801684) in which Nicanor Aquino is the identified Administrator. During the office visit, it was determined that Licensee Angelita Aquino have submitted training documents to the Administrator Certification Unit to renew their Administrator Certificate and it was agreed that acting administrator upon completing their required training hours, they will submit their renewal application. However, during today's visit, it was revealed that administrator certificate for acting administrator, Nicanor Aquino 6010494740 is still expired and Licensee are in the process of completing required training hours. Although, they claim that they are taking required training hours, there is no supporting evidence that they have submitted any required documentation for the Department to review, LPA was unable to find their names listed on the Department's pending/approved administrator certificate List. The Department will be reviewing the information obtained to determine if further actions are needed.

Licensee/acting Administrator to submit updates of the following documents by 7/16/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), 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 acting Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 2 of 8

Document Has Been Signed on 07/02/2024 03:59 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
CCLD Regional Office, 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: 07/02/2024

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 LPA's/acting administraor observation and interviews, the licensee did not comply with the section cited above in resident's rooms (room #3 & room #2) and common areas spider webs were observed, Two out of three bathrooms were observed dirty and needing minor repairs on walls. Window screen on room #3 needs to be replaced. All garbage cans do need to have a lid cover. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2024
	Plan of Correction
1 2 3 4	Licensee/acting administrator agreed to submit pictures as proof of repairs needed were resolved to CCL by POC due date to clear the citation.

Type A

Section Cited

CCR

87405(d)

Adminstrator - Qualifications and Duties

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/acting administrator observation, records review and interview, the licensee did not comply with the section cited above by not obtaining a valid administrator certification after informal meeting conducted on 6/28/23 with the Department or appointing an individual who had a valid administrator certificate, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2024
	Plan of Correction
1 2 3 4	Acting administrator and Licensee agreed to submit supporting documentation of training hours completed as of today to CCL by POC due date to clear the citation. The Department will be reviewing the information obtained to determine if further actions are needed.

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	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 3 of 8

Document Has Been Signed on 07/02/2024 03:59 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
CCLD Regional Office, 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: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 LPA's/acting administrator observation, interview and record review, the licensee did not comply with the section cited above in three out of five residents (R1, R2 & R3) needs an updated care plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/16/2024
	Plan of Correction
1 2 3 4	Acting Administrator agreed to submit a LIC9098 self-certification form ensuring that resident's care plans have been updated per regulation to CCL by POC due date to clear the citation.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024

LIC809 (FAS) - (06/04)

Page: 4 of 8