496801890-6-2-2022-21-AS-CFGS-CEZR7H-20220602124622

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496801890
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:48:31 PM

Document Has Been Signed on 06/02/2022 12:48 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:	PENNGROVE SHANGRI-LA		FACILITY NUMBER:	496801890
ADMINISTRATOR:	BACANI, MARIA CORAZON		FACILITY TYPE:	740
ADDRESS:	1762 WEISS LANE		TELEPHONE:	(707) 795-7921
CITY:	PENNGROVE	STATE: CA	ZIP CODE:	94951
CAPACITY:	6	CENSUS: 4	DATE:	06/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jesus Briones & Felicia Elefante - staff		TIME COMPLETED:	12:46 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 Analysts (LPA) Fernandes-Goes conducted an unannounced Annual 1 yr. Required & Case Management Non-Compliance Infection Control inspection to this facility and was welcome by staff Jesus Brioles. Facility has 4 residents with no one on hospice care at this time. Facility has activities for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 6/2/2022 with staff Jesus Briones, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, garage, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 1/2022 at the time of the visit. LPA conducted a sample test of Smoke Detectors & Carbon monoxide detector and they were operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Facility has no residents with special dietary need at this time. Food is available for residents any time of the day. Facility takes residents on walks, and conduct activities during the day such as singing. LPA observed during this visit unlocked toxins – Lysol under residents' bathroom and several different toxins under kitchen sink which is not locking properly. LPA was able to open the under-sink door without magnetic device. In addition, staff room wasn’t locked and had over the counter medications unlocked on top of dresser and unlocked garage with unlocked toxins. Sharps such as knives and scissors were found unlocked in a kitchen draw and countertop while staff S1 and S2 on shift were touring facility with LPA. Facility at this time has 2 out of 4 residents with a diagnosis of dementia. There was a supply of cleaners, hygiene products and paper products available for residents. (see copies, Picts, LIC 809-D) Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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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Document Has Been Signed on 06/02/2022 12:48 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: PENNGROVE SHANGRI-LA	FACILITY NUMBER: 496801890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 2 residents w/dementia which poses an immediate health, safety or personal rights risk to persons in care.Facility has 2 residents w/diagnosis of dementia -kitchen draw with sharps wasnt locked,unlocked toxins under bathroom sink & kitchen cabinet under the sink wasn't locked, unlocked ODC meds in staff room and toxins in garage.
	POC Due Date: 06/03/2022
	Plan of Correction
1 2 3 4	Facility to ensure that all medications, toxins, and sharps are locked and inaccessible to residents at all times. Facility licensee agrees to submit a selfcertification to the Department that all toxins, medications, sharps, and other items that might be of danger to residents in care has been properly lock by POC due date of 6/3/2022 in order to clear citation and avoid CPs.

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2022 12:48 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: PENNGROVE SHANGRI-LA	FACILITY NUMBER: 496801890
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview, and record review, the licensee did not comply with the section cited above in 2 out of 4 residents' reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.LPA learned that Resident R1 most resent reappraisal dated 9/28/2020 and Resident R3 reappraisal dated 11/2/2020.
	POC Due Date: 06/16/2022
	Plan of Correction
1 2 3 4	Facility to ensure that reappraisals are conducted at least every 12 months and/or any time there is a change of condition. Facility to provide Department with a copy of update reappraissal for residents R1 & R3 signed by resident and/or responsible party by POC due date of 6/16/2022 in order to clear citation and avoid civil penalties. (CP)

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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: PENNGROVE SHANGRI-LA	FACILITY NUMBER: 496801890
	VISIT DATE: 06/02/2022

NARRATIVE

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All bathrooms designated for residents at the facility were supplied with single paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility hot water temperature at residents' bathroom faucet measured between 118.8 degrees F and 120 degrees F in 2 out of 2 residents’ faucets within Title 22 acceptable regulations of 105 to 120 degrees F. All staff on shift during this visit is fingerprint cleared and associated to facility. During residents' file review due to unlocked toxins and sharps, LPA learned that there are 2 out of 4 residents' with reappraisals over 12 months. Resident R1 – diagnosis of dementia most resent reappraisal dated 9/28/2020 and Resident R3 – diagnosis of MCI reappraisal dated 11/2/2020. (see copies, LIC 809-D)

Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in small storage cabinet in living room. Facility has hired staff and admitted new residents since COVID-19.

Residents’ medications are stored and locked in kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; licensee/admin stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Visitors are being allowed in the facility. Residents have also available virtual and telephone calls when contacting with family members and others. Staff stated that all PPE training required and N-95 fit testing are on file. Disaster Drills have been conducted quarterly with the last one being conducted on 5/10/2022. Facility still has pending updated fire clearance. LPA contacted Fire Marshall AT who stated that another visit will be conducted.

Appeal of Rights Given.

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 conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC809 (FAS) - (06/04)

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