496801684-7-23-2024-21-AS-MCUA-D7FTDZ-20240723143911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801684
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:39:24 PM

Document Has Been Signed on 07/23/2024 02:39 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: 26	DATE:	07/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Charito Santos (Administrative Assistant)		TIME COMPLETED:	02:54 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 unnanounced to conduct a Required Annual Inspection and met with Charito Santos (Administrative Assistant), Nicanor Aquino (Licensee) arrived later. Annual fees are current. Required postings were observed. LPA/Administrative Asst. initiated the tour at 9:00am and made the following observations: Facility was a comfortable temperature with thermostat reading at 76 degrees F. Passageways were free from obstructions. Resident rooms needs a chair per resident per regulation (technical violation will be issued). During the tour of the facility LPA/Administrative Asst. bserved water temperature in resident bathroom measured at 124.3, 126.7, 106.1 and 126.3 degrees F, which are not within allowable range of 105 to 120 degrees F. Staff adjusted water heater immediately (Technical violation will be issued). Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cleaning supplies were also observed under the kitchen sink. Bathroom #2 windowsill have paint bubbles need to be cleaned; bathroom #1 sink needs to be cleaned; Resident's room (room # 10, 11, 13 and 17) window screens are missing. Face plate in room #10 needs to be replaced. Knives are located in a locked drawer in the kitchen. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked in a medication cart located in the office. Fire extinguisher was last inspected May 2024. Smoke and Carbon Monoxide detectors were tested during inspection and operational. Exit doors have auditory alert system that were functional at time of visit. Cash resources and records were reviewed. Emergency Disaster Drill has not been conducted within the last quarter. Medications and medication records were reviewed. 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: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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 07/23/2024 02:39 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: 07/23/2024

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 LPA's/Admin Asst. observation, interview and record review, the licensee did not comply with the section cited above in bathroom #2 windowsill have paint bubbles need to be cleaned; bathroom #1 sink needs to be cleaned; Resident's room (room # 10, 11, 13 and 17) window screens are missing. Face plate needs to be replaced in room #10, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2024
	Plan of Correction
1 2 3 4	Licensee/administrative asst. agreed to submit pictures as proof of repairs needed were resolved to CCL by POC due date to clear the citation.

Type A

Section Cited

CCR

87405(d)

Adminstrator - Qualifications and Duties

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/acting administrator observation, records review and interview, the licensee did not comply with the section cited above by not obtaining a valid administrator certification after informal meeting conducted on 6/28/23 with the Department or appointing an individual who had a valid administrator certificate, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit supporting documentation to the Department's certification unit and will send proof of submission to CCL by POC due date to clear the citation. The Department will be reviewing the information obtained to determine if further actions are needed.

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: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/23/2024 02:39 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: 07/23/2024

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 LPA's/Administrative Asst observation, interview and record review, the licensee did not comply with the section cited above in four out of four staff have not completed their additional 20 hours annually, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	Licensee agreed to have all staff complete required 20 hours annual training. Licensee will submit a self-certification form (LIC9098) to CCL ensuring that staff have completed required annual training hours. LPA will return to review training records.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Administrative Asst observation, interview and record review, the licensee did not comply with the section cited above by not conducting a drill at least quarterly for each shift, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	Licensee/Admin Asst agreed to perform a disaster drill at least quarterly for each shift. Licensee will submit a self-certification form (LIC9098) to CCL ensuring that staff have completed required annual training hours.

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: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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: 07/23/2024

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Continued from LIC809...
File review was initiated at 10:00 am. Five resident and four staff files were reviewed. Medical assessments, appraisals/needs and services plans are current. Staff have required First aid and CPR certificates. However, four out of four staff do not have required 20 hours additional training hours. Administrator Certificate for Nicanor Aquino 6010494740 expired October 7, 2023. Although, the licensee stated that they are taking required training hours. There is no supporting evidence that they have submitted any required documentation for the Department to review, LPA reached out to the administrator certification unit on 7/17/24 and they have not received a renewal/new application from any of the two licensees. The Department will be reviewing the information obtained to determine if further actions are needed.

During today's visit, LPA is also following up on SOC341 along with an incident report submitted to the Department on 6/20/24 involving two residents (R1 & R2). Per incident report, on 6/18/24 around 7pm, staff was assisting R1 with medications when R1 complained that there were only four medications and one was missing. Staff clarified to R1 that there were five tablets, but R1 kept insisting that there were only four tablets. R1 became anger, confronted R2, who was sitting in front of R1 that they have the right to complaint to staff, then both residents started pushing and hitting each other until R1 spit on R2. Staff called 911 immediately, police arrived and talked to both of them (SR #241700309). Later, R1 found the missing tablet under their table, then R1 stated that they accidentally dropped the tablet and apologized for their behavior. Responsible parties were notified. According to staff no further incidents have happened.

Licensee agreed to submit updates of the following by 8/13/2024: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Copy of Liability Insurance and Surety bond.

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 was conducted with Administrative Assistant 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: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC809 (FAS) - (06/04)

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