496801812-6-22-2023-21-AS-FSAI-CT2TAX-20230622143416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801812
Report Date: 06/22/2023
Date Signed: 06/22/2023 02:34:23 PM

Document Has Been Signed on 06/22/2023 02:34 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:	GREEN ACRES MANOR		FACILITY NUMBER:	496801812
ADMINISTRATOR:	HANSEN, JOSEPH		FACILITY TYPE:	740
ADDRESS:	9020 SONOMA HWY 12		TELEPHONE:	(707) 833-1171
CITY:	KENWOOD	STATE: CA	ZIP CODE:	95452
CAPACITY:	16	CENSUS: 14	DATE:	06/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Caregiver, Josiane Doignee Prospective Administrator, Elizabeth Lopez		TIME COMPLETED:	02:45 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 Green Acres Manor for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver, Josiane Doignee. Administrator, Elizabeth Lopez arrived 1 hour later. LPA toured the 1 story facility with the Care Giver, Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. However, LPA and Caregiver observed 2 of 2 laundry rooms unlocked and toxins were left accessible to residents in care (See LIC 809D and LIC 812-Observation/Photos). Fire Extinguishers were found to be last charged on December 2022 at the time of the inspection. Smoke Detectors and Carbon Monoxide Detectors sound directly to the Fire Department and could not be tested during the Required 1 year inspection. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured at 114 degrees, within Title 22 acceptable regulation of 105 to 120 degrees F in ALL resident’s bathrooms while touring facility. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the inspection. There was a supply of cleaners, hygiene products and paper products available for residents in care. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Medications were centrally stored in a locked cabinet. However, during a review of the Medication Orders, LPA observed 2 out of 2 residents did not have a prescribed medication (See LIC 809D and LIC 858) retained. LPA educated the Administrator regarding the importance of having ALL medications centrally stored and dispensed as outlined in Physicians Orders. First Aid kit was inspected and found to be appropriate during the Required 1 year 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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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: GREEN ACRES MANOR	FACILITY NUMBER: 496801812
	VISIT DATE: 06/22/2023

NARRATIVE

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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 advised to update the Infection Control Plan and send to Community Care Licensing (See LIC 9102-Technical Violation). LPA discussed the Emergency Disaster Plan with the Licensee/Administrator in detail and determined that an updated Emergency Disaster Plan will need to be sent to Community Care Licensing. During a tour of the facility, LPA observed an Emergency Generator in the front yard.

During the Required 1 year inspection, LPA reviewed 7 of 7 resident records. However, during one of the resident file reviews, LPA observed 3 out of 7 resident files did not have a current Reappraisal or an LIC 602. LPA educated the Licensee/Administrator regarding ensuring that Reappraisals are conducted as outlined in regulation (See LIC 9102-Technical Violation). In addition, LPA observed that 2 residents who are on Hospice did not have the staff training that were conducted with the Hospice agency retained in the facility files (See LIC 9102-Technical Violation). LPA educated the Administrator regarding the importance of having ALL training records from outside agencies are retained in files. LPA interviewed 7 of 7 residents in care during the Required 1 year inspection. LPA reviewed 4 of 4 staff member files and found insufficient training hours (See LIC 9102-Technical Violation). LPA interviewed 3 of 3 staff members. 3 out of 4 staff members did not have an Active First Aid/CPR card on file (See LIC 809D).

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
Fire Inspection Report
Updated facility sketch
Liability insurance
Control of Property
Register of residents
Most updated Infection Control Plan
Emergency Disaster Plan (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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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: GREEN ACRES MANOR	FACILITY NUMBER: 496801812
	VISIT DATE: 06/22/2023

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 26 27 28 29 30 31 32	The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted and a copy of this report along with appeal rights were given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/22/2023 02:34 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: GREEN ACRES MANOR	FACILITY NUMBER: 496801812
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 in 2 out of 2 laundry rooms were left unlocked and toxins were accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee shall submit a Plan of Correction which includes a Self-Certification LIC 9098 understanding the regulations. In addition, Licensee shall conduct staff training and provide a statement to licensing on how this regulation will be followed in the future.

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation/file review, the licensee did not comply with the section cited above in 3 out of 4 staff members not having an Active First Aid/CPR Card. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee shall submit a Plan of Correction which includes a Self-Certification LIC 9098 understanding the regulations. In addition, Licensee shall show proof of staff members scheduled for First Aid/CPR training and providing a statement on how this regulation will be followed.

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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 06/22/2023 02:34 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: GREEN ACRES MANOR	FACILITY NUMBER: 496801812
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(e)

Incidental Medical and Dental Care Services

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation/record review, the licensee did not comply with the section cited above in 2 out of 7 residents did not have the medication on record which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2023
	Plan of Correction
1 2 3 4	Licensee shall submit a Plan of Correction which will include an LIC 9098-Self Certification and to ensure that ALL resident medications are reviewed and the doctors notified if there are any medications missing, discontinuations needed or any updates to the Medication Administration of the residents in care. In addition, Licensee shall provide a written statement on how this regulation will be followed in the future.

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: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC809 (FAS) - (06/04)

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