496801575-11-16-2023-21-AS-CCOO-CX7SEZ-20231102134934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801575
Report Date: 11/02/2023
Date Signed: 11/16/2023 01:25:16 PM

Document Has Been Signed on 11/16/2023 01:25 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	IDAHO CARE HOME		FACILITY NUMBER:	496801575
ADMINISTRATOR:	RAMOS, CAROLINE		FACILITY TYPE:	740
ADDRESS:	3439 IDAHO DRIVE		TELEPHONE:	(707) 577-8233
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 5	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Administrator Caroline Ramos		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) Christi Coppo and Licensing Program Manager (LPM) Bethany Moellers arrived unannounced to conduct a required Annual inspection and was greeted by Rhodener (Dennis) Panlican, co-administrator. Licensee Caroline Ramos arrived later at approximately 11:45am. Facility currently has 5 residents of which none are on hospice. Facility contact information was reviewed. At approximately 9:00am LPA, LPM, and Licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA, LPM, and co-Administrator observed outside exit path to be partially obstructed by four shelving units, housing plants, and ceramics. LPA obtained photos and requested Licensee to remove all items so that pathway is fully accessible. Licensee agrees to have cement walkway from backyard area to emergency exit gate fully cleared and accessible. LPA and LPM advised path should be completely clear ensuring room for all residents to utilize path for emergency exit, as required by Title 22 regulation 87202(a). At approximately 8:55am LPA and LPM observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. Kitchen cabinet containing cleaning supplies was locked. LPA observed staff working in the kitchen with the sharp knives drawer unlocked. Licensee agrees to keep kitchen drawer containing sharp knives to be locked at all times, with the key removed and stored out of reach of residents. LPA observed staff to be in kitchen area working with medication cabinet unlocked and with keys in the lock. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 108.2 F, 111.4 F and 111.2 F degrees F which is within the allowable range of 105 to 120 degrees F.. Report continued on LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: IDAHO CARE HOME	FACILITY NUMBER: 496801575
	VISIT DATE: 11/02/2023

NARRATIVE

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Fire extinguishers were last inspected April 28, 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on August 10,2023. Facility has a backup generator for use during a power outage

At approximately 12:35pm LPA, LPM, and Licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the kitchen. At approximately 12:30pm LPA and Licensee observed medication cabinet to be unlocked in the afternoon. Licensee agrees to keep cabinet locked at all times, with the key removed and stored out of reach of residents.

At approximately 10:15am LPA and LPM conducted a review of 5 resident and 3 staff records. Current training courses and hours were not available for Arianna Panlican as required per Health and Safety Code 1569.625(b)(2).

Caroline Ramos Administrator Certificate 6039775740 expired 5/17/2022; however, certificate is currently in Renewal-Pending status. All fees are current as of this time.

LPA reviewed the facility's Infection Control Plan. Licensee provided the Infection Control Plan and will send copy of Infection Control Plan to CCL within 30 days.

At approximately 12:45pm LPA and LPM and co-Administrator observed the door leading to the garage to be unlocked. Garage entry has 3 steps leading down to garage area that could potentially pose a fall risk for residents. Co-Administrator agrees to change garage door handle to include a handle with a lock.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: IDAHO CARE HOME	FACILITY NUMBER: 496801575
	VISIT DATE: 11/02/2023

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LPA and Licensee discussed facility's Infection Control Plan. Licensee will send copy of Infection Control Plan to CCL within 30 days.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
Infection Control Plan
Evidence of Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/16/2023 01:25 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: IDAHO CARE HOME	FACILITY NUMBER: 496801575
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA, LPM, and co-Administrator observed outside exit path to be partially obstructed by four shelving units, housing plants, and ceramics, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Licensee agrees to have cement walkway from backyard area leading to emergency exit gate fully cleared and accessible. LPA and LPM advised path should be completely clear ensuring room for all residents to utilize path for emergency exit. Licensee agrees to submit photos of cleared pathway by POC date of 11/16/2023.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, record review, and Licensee admission, the licensee did not comply with the section cited above in [1] out of [3] staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/16/2023
	Plan of Correction
1 2 3 4	Licensee agreed to have staff (S1) member trainings completed by POC date of 11/16/2023.

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: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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