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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801600
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:14:12 PM


Document Has Been Signed on 05/24/2023 12:14 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:MT. VERNON GARDENSFACILITY NUMBER:
496801600
ADMINISTRATOR:DELLER, EMILCE & KIMFACILITY TYPE:
740
ADDRESS:3754 MT. VERNON RD.TELEPHONE:
(707) 829-3796
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 4DATE:
05/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Emilce Deller (Licensee)TIME COMPLETED:
12:29 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Emilce Deller. There are residents with a diagnosis of dementia or hospice.

LPA/Licensee initiated a tour of the facility and made the following observations: facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closets. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked in medication cabinet. Smoke and Carbon Monoxide detectors located throughout the facility that were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Medications and medication records were reviewed. Fire/disaster drill has been conducted in December, 2022. One ouf one fire extinguisher were last inspected May 2023. 4 staff files and 4 resident files were reviewed. Staff does have current required First Aid, CPR certificates and annual required training hours. 4 out of 4 residents does not have their medical assessment and care plans updated within the last 12 months. Licensee/LPA discussed their Emergency Disaster Plan & Infection Control Plan. Administrator Certificate for Administrator, Emilce Deller #6010293740 expires 2/26/2024. Required postings were observed. Water temperature in resident's bathrooms measured 105 and 105.1 degrees F which are within allowable range of 105 to 120 degrees F.

Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and copy of Liability Insurance.

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. Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
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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Document Has Been Signed on 05/24/2023 12:14 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: MT. VERNON GARDENS
FACILITY NUMBER: 496801600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2023

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/Licensee's file review showing that resident's care plans for 4 out of 4 residents (R1, R2,R3 & R4) were not been 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: 06/09/2023
Plan of Correction
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Licensee agreed to review all resident's care plans and physician's report, update them accordingly and send self-certification that this process had been done to CCL by POC due date.
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) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2023
LIC809 (FAS) - (06/04)
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