496800549-2-29-2024-21-AS-DALO-D2WTHR-20240229134511

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800549
Report Date: 02/29/2024
Date Signed: 02/29/2024 01:45:29 PM

Document Has Been Signed on 02/29/2024 01:45 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:	ALVAREZ FAMILY HOME		FACILITY NUMBER:	496800549
ADMINISTRATOR:	MUTUNGA, EMMA		FACILITY TYPE:	740
ADDRESS:	2185 FLORAL WAY		TELEPHONE:	(707) 545-6464
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 4	DATE:	02/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Emma Sila-Administrator		TIME COMPLETED:	02:00 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) Alviso conducted a Required- 1 Year inspection, on 2/29/24 at approximately 9:00am, and met with Administrator Emma Mutunga. The facility currently has four clients in care. All clients are at day program today. LPA reviewed four (4) resident files. All resident files were complete. LPA reviewed five (5) staff files. All staff have criminal record clearance as required. All staff had current First Aid and CPR as required. All staff had required annual training completed. Facility has a required infection control plan. Facility has a required emergency and disaster plan. LPA toured the facility with the Administrator. The home was clean and orderly. Hot water was checked at 120. degrees Fahrenheit All exits were clear. The fire extinguisher was serviced and tagged as required- expires 10/27/24. Facility has two carbon monoxide detectors- they were working properly during the inspection. All smoke alarms were working during the inspection. All common areas, hallways, bathrooms, and resident rooms had sufficient lighting for resident use. Facility had a sufficient supply of perishable and nonperishable food. Facility had a sufficient supply of hygiene products, paper products, and cleaning supplies. Medications were locked and inaccessible to residents in care. Toxins were locked and inaccessible from residents in care. Bathroom had grab bars and non-slip mat for resident use. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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 02/29/2024 01:45 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: ALVAREZ FAMILY HOME	FACILITY NUMBER: 496800549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Per LPA’s record reviews, four (4) staff lack required medication training per H&S Code], the licensee did not comply with the section cited above in [4] out of [5] staff which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	Licensee to ensure the four staff obtain medication training as required per H&S Code; Submit proof of staff's medication training by 3/18/24. Submit your plan of correcting this deficiency by 3/1/24.

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

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: ALVAREZ FAMILY HOME	FACILITY NUMBER: 496800549
	VISIT DATE: 02/29/2024

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 3/27/24:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan- review and submit (provide all information in all boxes as required)
Infection Control Plan- review and submit (provide all information as required)
Copy of LIC400 Handling of Client Cash Resources (complete the form even if not handling cash)
Copy of required Surety Bond (if handling cash)
Copy of Current required Liability Insurance
Copy of current Administrator Certificate

Per LPA’s record reviews, four (4) out of five (5) staff lack required medication training per H&S Code. This deficiency will be cited, H&S 1569.69 (2) (a) Employees assisting residents with self-administration of medication; training requirements- A facility who assists residents with the self-administration of medications meets all of the following training requirements: In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment, see LIC809D.

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.

Appeal rights were provided Exit interview conducted with Administrator Emma Mutunga. .Report signed and provided to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 02/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024

LIC809 (FAS) - (06/04)

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