496801684-7-20-2023-21-AS-MCUA-CTWRTC-20230720131806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:18:17 PM

Document Has Been Signed on 07/20/2023 01:18 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 HOMES		FACILITY NUMBER:	496801684
ADMINISTRATOR:	AQUINO, NICANOR		FACILITY TYPE:	740
ADDRESS:	857 HEARN AVE.		TELEPHONE:	(707) 546-8413
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY:	40	CENSUS: 30	DATE:	07/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Nicanor Aquino (Administrator)		TIME COMPLETED:	01:33 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 was greeted by Administrative Assistant, Charito Santos. Licensee Angelita Aquino and Administrator Nicanor Aquino arrived later. Required postings were observed. LPA initiated a tour of the facility around 8:45am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Residents room were furnished per regulation. Water temperature in bathroom used by residents measured 114.1, 113.5, 111.4 and 119.8 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies are stored in the locked laundry room. Facility has at least two days of perishable and one week of non-perishable foods. Facility has emergency food and water supplies. Fire extinguisher was last serviced June 2023. Smoke detectors located throughout the facility as well as the Carbon Monoxide detector were tested and operational during inspection. Knives are located in a locked drawer in the kitchen. Kitchen staff were in kitchen at the time of inspection and LPA confirmed that the kitchen was locked when staff were not in the kitchen. Exit doors have auditory alert system that were functional at time of visit. All fees are current as of this time. Reviewed current Contact Information. Administrator Certificate for Nicanor Aquino 6010494740 expired, but there was proof that it is listed on the Department's pending Administrator Certificate list. Last emergency disaster drill conducted in May 2023. At approximate 9:00am LPA/staff observed one out of four bathrooms used by residents located in wing "A" had a urine smell, ceiling in the bathtub area was peeling off, the bathtub was dirty and unsanitary including curtain that needs to be replaced. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: AA BEST CARE HOMES	FACILITY NUMBER: 496801684
	VISIT DATE: 07/20/2023

NARRATIVE

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Continued from LIC809...

At approximate 10:00am LPA/staff conducted file review. Ten residents and six staff files were reviewed. All ten residents appraisals/needs and services plans and medical assessments were current. Staff have required First aid and CPR certificates. However, three out of six staff (S1, S2 & S3) have not met the training additional 20 hours requirement.

At approximate 11:00am LPA/staff conducted a spot check of medications and it was revealed during medications review that 10 out of 10 resident's (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) medication log were not entered into the Centrally Stored Medication Log within the last 12 months. Also, six out of ten (R1, R2, R3, R4, R5 & R6) resident's medications for the evening had already been poured. LPA instructed staff that pre-pouring medication was not allowed and medication must stay in it's original container. Medications were centrally stored and locked in a medication cart located in the office.

Licensee/Administrator to submit updates of the following documents by 8/1/2023:

-LIC 500 Personnel Summary
-LIC308 Designation of Facility Responsibility.
-Copy of Liability Insurance
-LIC 610 Emergency Disaster Plan (If changes)
-Infection Control Plan (If changes)

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 Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2023 01:18 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: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above because LPA/staff observed one out of four bathrooms used by residents located in wing "A" had a urine smell, ceiling in the bathtub area was peeling off, the bathtub was dirty and unsanitary including curtain that needs to be replaced, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2023
	Plan of Correction
1 2 3 4	Licensee agreed to repair items that were dirty including, curtain, bathtub area and ceiling, staff cleaned the bathroom during LPA inspection. Licensee/Administrator will submit self-certification LIC9098 form along with pictures to indicate that repairs are within CCL regulations by POC due date. LPA will return to inspect areas of concerns.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2023 01:18 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: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 6 staff have not complete 20 additional hours training requirements, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator agreed to have staff complete training and send to CCL with form LIC9098 by POC due date to clear deficiency.

Type B

Section Cited

CCR

87465(h)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	***duplicate. Citation already issued under CCR 87465 (h)(6)
	POC Due Date: 07/24/2023
	Plan of Correction
1 2 3 4	***duplicate. Citation already issued under CCR 87465 (h)(6)

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: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2023 01:18 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: 07/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the evening medications already poured and being stored in a separate container, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2023
	Plan of Correction
1 2 3 4	Facility will stop pre-pouring medications immediately and submit self-certification that medication will be stored in it's original container per regulation by POC due date 7/24/2023.

Type B

Section Cited

CCR

87465(h)(6)

87465 (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining a Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2023
	Plan of Correction
1 2 3 4	Facility to review and update the Centrally Stored Medication Log by POC due date, 7/24/2023. LPA will return to review.

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: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023

LIC809 (FAS) - (06/04)

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