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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 08/25/2023
Date Signed: 08/25/2023 02:29:13 PM


Document Has Been Signed on 08/25/2023 02:29 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: 30DATE:
08/25/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Angelita Aquino (Licensee)TIME COMPLETED:
02:44 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting a plan of correction visit and follow up on self-incident report and met with Licensee, Angelita Aquino.

LPA is following up regarding deficiencies cited during the July 20, 2023 Annual Required inspection.

The following deficiencies have been corrected:
87303 (a) - Bathrooms used by residents located in wing "A" ceiling in the bathtub area was repaired, the bathtub was cleaned including curtain was replaced.
87465(h)(5) - Medication is no longer being pre-poured.
87465(h)(6) - Centrally Stored Medication Log is maintained.
1569.625 (b)(2) - staff have complete 20 additional hours training requirements.

LPA is following up on self-incident report filed by the facility Administrator to CCL on 8/8/23. Per incident report, On 8/3/23 around 9:15pm resident (R1) was found by staff on the floor with blood on their nose. Staff called 911 immediately to transport R1 to the hospital for further evaluation. Responsible parties were notified. R1 was discharged the same day with a diagnosis of closed fracture of their nasal bone. During today's visit, LPA reviewed R1's records, Physician's Report (LIC602) and discharge documents dated 8/3/23 indicating that R1 sustained a fracture with no follow up appointment. Based on Physician's report (LIC602) dated 7/22/22 R1 is ambulatory, has a history of falls, and they are able to perform all daily activities independently.

No deficiencies cited during today's inspection.
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: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
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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