496803065-9-9-2021-21-AS-SHAN-C6PTHT-20210909144517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803065
Report Date: 09/09/2021
Date Signed: 09/09/2021 02:45:26 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	MAEGAN'S CARE HOME		FACILITY NUMBER:	496803065
ADMINISTRATOR:	CORALDE, LILIA		FACILITY TYPE:	740
ADDRESS:	2812 BETH COURT		TELEPHONE:	(707) 527-9906
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 4	DATE:	09/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Administrator Lilia Coralde		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

At 12:40 PM on 9/9/2021 Licensing Program Analyst Hansen arrived unannounced to conduct a required Annual 1 yr. Infection Control inspection and met by Administrator Lilia Coralde. Facility has 4 residents at this time with one on hospice.

LPA arrived at the facility and had temperature checked and logged into visitor’s binder. The facility was a comfortable temperature, free from obstructions. and was well lit. Extra hygiene products and linens were available and required bath mats and grab bars were observed. Water temperature in resident's bathrooms measured 105.2 degrees F and 106.1 degrees F which are within acceptable range of 105 to 120 degrees F. Cleaning products and other toxins are located in the locked cabinet under sink & in garage. Knives are kept in a locked cabinet in the kitchen. Medications were centrally stored and locked in living room closet. Fire extinguisher located in the kitchen was last inspected 8/02/2021. Smoke detectors located throughout the facility and carbon monoxide detector were tested and functional. Exit doors have auditory alert system.

Perishable and non-perishable foods were sufficient, although Administrator told LPA market day is in two days. Administrator told LPA last disaster/fire drill was May of 2021 and are usually practiced every quarterly.

S1, S2, & S3 do not have current required 1st Aid and CPR training.

Infection Control:

Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has small table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in living room closet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility. All staff had masks on during this visit. Staff had all PPE training required on file and have obtained N-95 fit testing.

Continue LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MAEGAN'S CARE HOME	FACILITY NUMBER: 496803065
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 interview the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 2 out of 2 caregivers that work at the facility without a valid CPR certificate which poses an immediate health, safety risk to residents in care
	POC Due Date: 09/23/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that at least one staff on duty has CPR training at all times. Licensee to submit LIC 9098 self certification that staff have been CPR trained per regulation and that facility will maintain a staff on duty who has CPR training at all times by POC due date 9/23/2021.

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff files review & interview with Licensee, the facility did not ensure that all staff have current 1st aid. LPA learned that 3 of 3 staff (S1) (S2) & (S3), does not have proof of current first aid certification which poses a potential health & safety risk to residents in care.
	POC Due Date: 09/23/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1, S2, & S3 to CCL by POC date of 9/23/2021.

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MAEGAN'S CARE HOME	FACILITY NUMBER: 496803065
	VISIT DATE: 09/09/2021

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

LPA Hansen reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. In addition, LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA Hansen is requesting Licensee to update and submit the following documents by 9/23/2021:

Current CPR & 1^st Aid Training Certificates

LIC 308 Designated

LIC 309 Administrative Organization

Articles of Corporation

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3