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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800304
Report Date: 02/20/2024
Date Signed: 02/20/2024 12:45:43 PM


Document Has Been Signed on 02/20/2024 12:45 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 HOMEFACILITY NUMBER:
496800304
ADMINISTRATOR:LUELLEN, LADANA B.FACILITY TYPE:
740
ADDRESS:538 MARIA DRIVETELEPHONE:
(707) 762-9296
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:5CENSUS: 5DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ladana Luellen, Licensee/AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual inspection visit of the facility. LPA was welcomed by Licensee/Administrator, Ladana Luellen. There is a total of 5 residents in care, 2 currently on Hospice, 1 with dementia.

LPA toured the facility on 2/20/2024 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; (although they were not turned on during today’s visit (see LIC809-D). Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Fire extinguishers were last checked 10/13/2023. Hot water temperature measured between 114.9 degrees F and 118.5 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 3 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.

A review of five resident & two staff records as well as medication audit was conducted. LPA reviewed resident’s files at 10:00 AM on 2/20/2024 and learned that 1 of 5 residents (R1) do not have an appraisal or updated re-appraisals/needs & care plan (see LIC809-D) and 5 out of 5 residents physician’s assessments (LIC 602A) are updated as required by Title 22 Regulations on file.

Continue on LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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 02/20/2024 12:45 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: WELL CARE HOME
FACILITY NUMBER: 496800304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

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
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Based on LPA/Administrator's file review showing that resident's care plans for 1 out of 5 residents (R1) was not performed and signed by the resident of their representative within last 12 months. This is a potential risk to the health and safety of residents in care.
POC Due Date: 02/29/2024
Plan of Correction
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Administrator agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review & interview, the licensee did not comply with the section cited above in not conducting a drill since 2/2/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee to conduct and log disaster drill and send LIC9098 Proof of correction and indicate they understand the regulation.
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) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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: 02/20/2024
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Medications were centrally stored in locked cabinet in the facility kitchen. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 2/20/2024 at 11:30 AM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA reviewed a sample of staff records at 11:45 AM on 2/20/2024 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. LPA observed during staff file review that facility has proof on 2/20/2024 at 11:00 AM of direct care staff annual training requirements for 2023. LPA was presented with proof of CPR although 1st Aid certification for Licensee expired. (see LIC 9102 Advisory Notes) Ladana Luellen Administrator Certificate # 6015414740 expires on 4/10/2024. Facility’s last recorded disaster drill was 2/2/2023 falling out of Title 22 Regulations (see LIC809-D).

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided

LPA Hansen is requesting Licensee to update the following documents by 3/20/2024:



LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/20/2024 12:45 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: WELL CARE HOME
FACILITY NUMBER: 496800304

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
87705(j)Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on observation the licensee failed to have auditory devices turned on on 3 of 5 auditory devices which poses an immediate health, & safety risk to residents in care. LPA toured the facility with staff on 2/20/24 and tested all auditory devices in the facility; 3 of the auditory devices at the facility weren't activated; front door, backyard door from dinning room, & Room #1 at the time of the visit.
POC Due Date: 02/29/2024
Plan of Correction
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Licensee to ensure all door alarms are on & working appropriately at all times. Licensee to turn all auditory devices on, and to provide form LIC 9098 proof of certification with a written statement signed that facility staff understands that auditory devices must be turned on at all times, and that all auditory devices are working properly to CCL by POC due date 2/29/2024.
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) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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