496800304-3-2-2022-21-AS-SHAN-CC5UL7-20220302144017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800304
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:40:23 PM

Document Has Been Signed on 03/02/2022 02:40 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:	WELL CARE HOME		FACILITY NUMBER:	496800304
ADMINISTRATOR:	LUELLEN, LADANA B.		FACILITY TYPE:	740
ADDRESS:	538 MARIA DRIVE		TELEPHONE:	(707) 762-9296
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	5	CENSUS: 3	DATE:	03/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:31 PM
MET WITH:	Licensee Ladana Luellen & Executive Director Arthur Lee Luellen		TIME COMPLETED:	02:40 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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. infection control inspection visit of the facility. LPA was welcomed by Arthur “Lee” Luellen, Licensee Ladana Luellen arrived during inspection. There is a total of 3 residents'; no dementia residents. There are no residents currently on Hospice. LPA toured the facility on 3/02/2022 at 1:20 PM with staff Arthur “Lee” Luellen; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices; all auditory devices were working properly. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Fire extinguishers were last checked 10/12/2021. Hot water temperature measured between 114.0 degrees F and 114.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 3/02/2022. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry room. Dangerous items were found stored inaccessible to residents with dementia. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Medications were centrally stored in locked cabinet in facility office/kitchen. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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: WELL CARE HOME	FACILITY NUMBER: 496800304
	VISIT DATE: 03/02/2022

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Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 3/24/2021. All staff and visitors check in and log temperatures and either have proof of vaccinations on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in laundry room and hallway cabinet shelf. Facility has a 30-day supply of medication for residents. Staff had all PPE training required as well have been N95 Fit Tested. All staff have been fully vaccinated and received their COVID booster shots and all staff work exclusively at this facility.

In addition, facility has designated areas for visitors in back yard. Residents also have available facetime and telephone calls when contacting with family members and others and assistance if needed. Facility conducts disaster drills quarterly with the last being 1/2022.

LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time; no need to change any of the information other than add Licensee’s cell number. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/15/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC809 (FAS) - (06/04)

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