496801575-10-23-2024-21-AS-CCOO-DABQPZ-20241023122134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801575
Report Date: 10/23/2024
Date Signed: 10/23/2024 12:21:54 PM

Document Has Been Signed on 10/23/2024 12:21 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: 6	DATE:	10/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Caregiver		TIME COMPLETED:	12:36 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 arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Admin not present at facility but available via telephone. Admin arrived later. At approximately 9:15am LPA and caregiver toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA 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. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. 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 bathroom had required bath mat and grab bar. Water temperature in sink accessible to residents in care measured at 110 and 108.1 degrees F which is within the allowable range of 105 to 120 degrees F. LPA and caregiver observed resident (R1) to have strong smell of urine on her person. LPA verified that urine smell is not from urine soaked bed or furniture. LPA discussed with Admin and caregiver that resident must be kept free of incontinence odor and be kept clean and dry. Resident is currently on hospice and has pressure wound/ulcer which makes incontinence care even more crucial. Caregiver will now document every time resident refuses a shower and every time a sponge bath is given. Fire extinguishers were last inspected 5/17/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills were conducted 8/10/2024 Facility has a backup generator for use during a power outage. Continued on 809C...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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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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: 10/23/2024

NARRATIVE

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Continued from 809...

At approximately 10:00am LPA conducted a review of 6 resident records. 1/2 rails on file for respective residents. No deficiencies cited.

At approximately 11:00am LPA conducted review of 4 staff records. No deficiencies cited.

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies cited. LPA and Admin discussed pre-pouring medications. LPA advised Admin that all medications must be live poured or prepared just before giving to resident. Meds cannot pre-poured.

Caroline Ramos Administrator Certificate 7011795740 is expired but currently in pending-renewal status. All fees are current as of this time.

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
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 and discussed with Licensee. 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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/23/2024 12:21 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: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87625(b)(3)

Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and caregiver observation the licensee did not comply with the section cited above in that R1 had strong smell of urine on her person, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/06/2024
	Plan of Correction
1 2 3 4	Facility to ensure R1 remains free of incontinence odors and remains clean and dry. Facility to submit 2 week shower refusal.sponge bath log by plan of correction due date.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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