<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801600
Report Date: 06/11/2024
Date Signed: 06/11/2024 03:05:41 PM


Document Has Been Signed on 06/11/2024 03:05 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: 6DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:43 PM
MET WITH:Emilce Deller (Licensee)TIME COMPLETED:
03:20 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) Cuadra arrived unannounced to conduct an Annual required inspection and met with Licensee, Emilce Deller. Fees are current. Contact information was reviewed. There are residents with diagnosis of dementia.

LPA initiated a tour of the facility at 1:00 pm and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 105.3 and 106.1 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Toxins were inaccessible to residents in care. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected June, 2024. Smoke detectors and carbon monoxide detectors located throughout the facility were tested and operational. Exit doors have auditory alerts that were functional at time of visit. Last disaster drill was conducted on 3/23/24.

File review was initiated at 1:30 pm. Three staff files and six resident files were reviewed. One out of three staff do not have required 1st Aid/CPR certificates (technical violation issued). One out of six residents (R1) do not have a current medical assessment within the last 12 months. Three out of six residents (R1, R2 & R3) do not have a care plan updated within the last 12 months as indicated in regulation. Administrator Certificates for Licensee Emilce Deller, 6010293740, expires on 2/26/26. Training records were reviewed.

Licensee agreed to submit updates of the following documents by 6/28/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and control of property.

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: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 06/11/2024 03:05 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: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA/Licensee's observation, interview and record review, the licensee did not comply with the section cited above in one out of six residents do not have a current medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee agreed to obtain current medical assessment and will submit a self-certification form (LIC9098) to CCL ensuring that they have obtained a current documentation to clear the deficiency.
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
1
2
3
4
Based on LPA/Licensee's observation, interview and record review, the licensee did not comply with the section cited above in three out of six residents do not have a current care plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee agreed to obtain current care plan and will submit a self-certification form (LIC9098) to CCL ensuring that they have obtained a current documentation to clear the deficiency.
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: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3