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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 03/28/2023
Date Signed: 03/28/2023 02:18:12 PM


Document Has Been Signed on 03/28/2023 02:18 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:AA BEST CARE HOMESFACILITY NUMBER:
496801684
ADMINISTRATOR:AQUINO, NICANORFACILITY TYPE:
740
ADDRESS:857 HEARN AVE.TELEPHONE:
(707) 546-8413
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:40CENSUS: 29DATE:
03/28/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Charito Santos (Administrator)TIME COMPLETED:
02:33 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a case management to follow up on two self-incident reports and met with facility Administrator, Charito Santos.

LPA is following up on self-incident report filed by the facility Administrator to CCL on 2/10/23. Per incident report, On 2/8/23 around 12:20pm resident (R1) screamed and was found by staff sprawled on the floor, informed us that they slipped while walking and hit their head on the wall. Staff called 911 immediately and transported R1 to the Hospital. R1 was discharged same day with a diagnosed with fracture in left shoulder after a fall. During today's visit, LPA reviewed R1's records including their care plan, Physician's Report (LIC602) and discharge documents dated 2/8/23 indicating that R1 sustained a fracture and follow up appointment next day with their Physician were it was determined that R1 does not need surgery and has another follow up appointment on 12/16/22. LPA also made observations to residents in care and conducted interviews with facility staff and residents that concluded R1 had an un-witnessed fall while walking in the hallway. Based on Physician's report (LIC602) dated 2/7/23 and R1's care plan dated 5/22/20 R1 is able to perform ADL's independently.

The second self-incident report was received on 3/20/23 notifying CCL that on 3/15/23 around 5:30pm the facility received notification that R2 was going to be transferred to skilled nursing due to a wound that developed in their tail bone for sitting on their walker. During today's visit, LPA reviewed R2's Physician Report (LIC602) dated 12/28/22 that did not indicate any history of skin condition, R2 is ambulatory and able to perform ADL's independently. R2's care plan dated 5/1/20 confirmed that they use a walker to get around the facility. LPA discussed with Administrator that care plans are not current; Administrator agreed to update care plans and obtain R2's discharge documents to send them to LPA for review.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
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 03/28/2023 02:18 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: AA BEST CARE HOMES
FACILITY NUMBER: 496801684

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited

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87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by:
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Administrator agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date.
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Based on LPA/Administrator's file review showing that resident's care plans for 2 out of 2 residents (R1 & R2) 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.
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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: 03/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
LIC809 (FAS) - (06/04)
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