496800304-2-13-2023-21-AS-SHAN-CNZNBW-20230213091949

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800304
Report Date: 02/13/2023
Date Signed: 02/13/2023 09:20:02 AM

Document Has Been Signed on 02/13/2023 09:20 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:	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: 5	DATE:	02/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Assistant Administrator Arthur Luellen		TIME COMPLETED:	09:25 AM

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 was not available for today’s inspection. There is a total of 5 in care Residents, 3 currently on Hospice, 1 with dementia. LPA toured the facility on 2/13/2023 at 8:45 AM 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 10/11/2022. Hot water temperature measured between 119.5 degrees F and 119.7 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility. 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 paper 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. Infection Controle: Facility has submitted a mitigation program plan and infection control plan. All staff and visitors check in and log temperatures. 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. 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: 02/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: WELL CARE HOME	FACILITY NUMBER: 496800304
	VISIT DATE: 02/13/2023

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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 12/2022.

LPA reviewed Licensing Information System (LIS) with designee who stated that is correct and updated at this time. 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 current CPR & 1^st Aid certification for staff.

Administrator Certificate is for Ladana Luellen # 6015414740 Exp.4/10/2024
All staff have received COVID booster vaccinations.

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 SRRO:

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

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2023

LIC809 (FAS) - (06/04)

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