496801807-7-25-2023-21-AS-FSAI-CU3T45-20230725142322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801807
Report Date: 07/25/2023
Date Signed: 07/25/2023 02:23:35 PM

Document Has Been Signed on 07/25/2023 02:23 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:	YERBA BUENA RESIDENTIAL CARE HOME		FACILITY NUMBER:	496801807
ADMINISTRATOR:	MARTINEZ, ANGELICA		FACILITY TYPE:	740
ADDRESS:	5200 YERBA BUENA		TELEPHONE:	(707) 539-6780
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	6	CENSUS: 6	DATE:	07/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Caregiver, Noel Marayag		TIME COMPLETED:	01:30 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), Farhaan Sarangi arrived unannounced at Yerba Buena Residential Care Home for the purpose of conducting a Required 1 year inspeciton. LPA was greeted at the door by Caregiver, Noel Marayag and was granted access into the facility. During a review of the Guardian Background Clearance Roster, LPA observed that 1 out of 2 staff members did not have a Background Clearance (See LIC 809D & Civil Penalty). Caregiver, Noel Marayag disclosed to the LPA that the Uncleared Adult just started working yesterday, July 24, 2023. LPA attempted to get Identification from the Uncleared Adult, but the Uncleared adult did not have any identification. While setting up the LPA laptop on the kitchen table, LPA observed a camera with audio in the kitchen credenza closest to the fridge monitoring a resident in placement (See LIC 9102-Technical Violation). Caregiver disclosed that the camera was put in by the family. LPA advised to remove the camera. LPA gave Technical Assistance to the facility if the families want to install cameras in the room. LPA and Caregiver toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on October 2022 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Auditory Devices were operational during the inspection. First Aid kit cart was inspected and found to be appropriate during the inspection. Water temperature in 3 of 3 residents bathroom measured at 105 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Activities menu was available for viewing during the inspection. Medications were centrally stored and locked in the closet. Cleaning products and other toxins are located in the locked laundry room and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents in care during the inspection. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

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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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: YERBA BUENA RESIDENTIAL CARE HOME	FACILITY NUMBER: 496801807
	VISIT DATE: 07/25/2023

NARRATIVE

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All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

Staff files, resident files and medication files will be reviewed at a later date and time. Staff and resident interviews will also be conducted at a later date and time. Emergency Disaster Plan was reviewed. Emergency Generator was observed in the garage.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA discussed the Infection Control Plan with the Caregiver and advised to update Infection Control Plan. To update the Infection Control Plan, see below:

https://www.cdss.ca.gov/inforesources/forms-brochures/forms-alphabetic-list/i-l

LIC 9282 (6/23) – Residential Infection Control Plan - Adult Residential Facilities, Enhanced Behavioral Supports Homes, Community Crisis Homes, Residential Care Facilities for the Elderly, Residential Care Facilities for the Chronically Ill, and Social Rehabilitation Facilities

Emergency Disaster Plan was discussed. A review of the Emergency Disaster drill reflects the last time a drill was conducted was on March 2021 (See LIC 9102-Technical Violation). LPA educated the Caregiver regarding the importance of conducting quarterly disaster drills as outlined in Title 22 regulations.

The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed (See LIC 421M dated for June 5, 2023) Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview conducted with the Caregiver, appeal rights provided and Caregiver provided this report.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/25/2023 02:23 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: YERBA BUENA RESIDENTIAL CARE HOME	FACILITY NUMBER: 496801807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(a)

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and Guardian Review, the licensee did not comply with the section cited above in 1 out of 2 staff members were not background cleared which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty Assessed.
	POC Due Date: 07/26/2023
	Plan of Correction
1 2 3 4	Plan of Correction shall include a statement regarding future compliance. Licensee shall fill out at LIC 9098 Self-Certification form reading and understanding the regulation as it relates to Criminal Record Clearance. Furthermore, Licensee shall associate any individuals that provide care and supervision to residents in care.

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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC809 (FAS) - (06/04)

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