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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 06/13/2022
Date Signed: 06/13/2022 11:45:16 AM

Document Has Been Signed on 06/13/2022 11:45 AM - 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:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Charito Santos (Administrator)TIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with individual (I1) and Administrator Charito Santos. Licensee Nick Aquino arrived later. LPA/Administrator reviewed PIN 22-07, 22-09, 22-13, 22-15 and 22-16.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. At approximate 9:30am LPA learned through interviews with staff that individual ( I1) had been working providing care and supervision to residents in care for one day and has not been associated to the facility yet, LPA informed Licensee that individual (I1) is fingerprint, but they are not associated to the facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. LPA/Administrator conducted a walk-through of the facility and observed approximately 9:35am expired food. There was 16 boxes of expired cake mix, 2 boxes of value size expired Cheerios cereal, 3lbs of expired sour creams, 1 expired cranberry jelly and an expired bag of bread rolls. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene and paper products. Commonly touched surfaces are disinfected at least twice a day. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents are able to receive indoor visitation with their families and facility is able to perform antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes.

Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2022
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: 06/13/2022
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Continued from LIC809...

Facility has submitted their Covid Mitigation Plan and approved on 5/19/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are accessible for staff.

Licensee will provide updates of the following by 6/27/22: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Liability insurance and Emergency Disaster Plan (LIC610E).

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. Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance exemption.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/13/2022 11:45 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 06/13/2022 at 10:35 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance (e)All individuals... shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Dpt...This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, record review and interview with Licensee did not ensure to obtain a criminal record clearance for individual (I1) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care. ***Civil Penalty is being assessed for the amount of $100 per day.
POC Due Date: 06/14/2022
Plan of Correction
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Licensee removed individual (I1) from the facility until I1 has a clearance as required by regulation. Licensee will associate individual and will submit a LIC9098 self-certification that I1 was removed from facility to CCL by POC due date.
Type A
Section Cited
CCR
87555(a)(8)(28)

General Food Service Requirements (a)(8(28) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. All food shall be protected against contamination. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews conducted with Licensee, the facility did not ensured that expired food located in the pantry closet and in the refrigerator was discarded which is an immediate health and safety risk to residents in care.
POC Due Date: 06/14/2022
Plan of Correction
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Licensee/Administrator to submit a written plan of maintenance regarding ensuring all food is of good quality at all times-and refrigerator is checked regularly for this. Licensee/Administrator to check refrigerator and discard any expired food and submit written confirmation of doing this by POC due date.
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
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022


LIC809 (FAS) - (06/04)
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