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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803065
Report Date: 10/19/2022
Date Signed: 10/19/2022 04:03:31 PM


Document Has Been Signed on 10/19/2022 04:03 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:MAEGAN'S CARE HOMEFACILITY NUMBER:
496803065
ADMINISTRATOR:CORALDE, LILIAFACILITY TYPE:
740
ADDRESS:2812 BETH COURTTELEPHONE:
(707) 527-9906
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 4DATE:
10/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lilia Coralde-AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Dina Alviso conducted a Required-- 1 year inspection and met with Licensee/Administrator, Lilia Coralde. The inspection is focused on the Infection Control practices and procedures of this facility.

The LPA toured the facility with the Licensee Lilia Coralde. The LPA observed that there was a sufficient supply of food, perishable and nonperishable. A sufficient supply of paper products, cleaners, and hygiene products for residents in care. There is a closet where medications are to be stored and locked.

The LPA observed that upon entry a staff cook and a staff driver did not wear masks as required. by regulations.

LPA observed that two fire extiguishers were not annualy serviced and tagged as required-both fire extinguishers were expired, dated 8/2/21. LPA observed that a resident room had their fire exit slider door blocked by a feeding tray on wheels, and on the outside of the door it was blocked by a hoyer lift. There was a stick in the slider door floor track which keeps the door from fully opening. The garage is being used as a sleeping area for a staff person-LPA observed staff's personal belongings, including numerous medications/medication supplies. Fire Safety 87203 deficiency will be cited-see LIC809D.

LPA observed numerous medications left out in the kitchen, a small refrigerator with numerous medications unlocked , a resident RM with three medications on the dresser.
Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
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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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: MAEGAN'S CARE HOME
FACILITY NUMBER: 496803065
VISIT DATE: 10/19/2022
NARRATIVE
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Numerous medications in the garage belonging to the staff that sleeps in the garage. All these medications were unlocked, making them accessible to residents in care. 87465 (h)(2) Incidental Medical and Dental Care will be cited-see LIC809D

LPA was not screened upon entry into the facility as required. Deficiency cited 87405(d)(2) Administrator Qualifications and Duties-see LIC809D.
LPA observed staff not wearing masks as required. Deficiency cited Personal Rights 87468.1(a)(2)- see LIC809D.
LPA observed a pile of tools on the floor outside of the door leading to the backyard.-accessible to residents in care. Deficiency cited-87705(f)(1)-see LIC809D.
LPA found during the tour that the floor plan of resident rooms has changed; Staff now live in the facility and use room #4. Licensee stated room 4 has been used by staff for a couple years now. There are four resident rooms, and one staff room, and the small office room. Licensee to submit LIC200 and updated facility sketch as required by regulation. Only four residents may be serviced by the facility per inspection. Deficiency cited-87208 Plan of Operation-see LIC809D.

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.

Licensee/Administrator agrees to submit the following documents by 10/31/22:


LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 9020 Register of Residents
LIC 610 E Emergency Disaster Plan for Residential Care Facilities for the Elderly
Copy of Liability Insurance
Copy of the Infection Control Plan
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/19/2022 04:03 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: MAEGAN'S CARE HOME
FACILITY NUMBER: 496803065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited

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Personal Rights 87468.1(a)(2)- Residents in assited living.-ensuring personal rights are not violated at any time. This requirement is not met as evidenced by: LPA's observations during the inspection. LPA observed two staff (3, 4) not wearing masks in the facility.
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LPA asked the staff to put on masks as required.LPA asked staff 3 to put the mask over their nose as well, as LPA observed it below staff's nose-not worn correctly. Staff complied. This deficiency iis a risk to health & safety and/or a personal rights risk to residents in care.
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Licensee o submit in-service with all staff regarding staff wearing masks in the facility at all times. Submit proof of training by 10/24/22. Submit plan of correction by 10/20/22.
Type A
10/20/2022
Section Cited

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Administrator Qualifications and Duties- 87405(d)(2) 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:
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement is not met as evidenced by::
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LPA's observations, staff did not screen the LPA when having them enter the facility or at any time once inside the facility. This deficiency iis a risk to the health & safety and/or a personal rights risk to residents in care.
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be in compliance with the required screening.of visitors, and staff. Residents are to be screened and observed as needed. POC sue 10/20/22
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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 10/19/2022 04:03 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: MAEGAN'S CARE HOME
FACILITY NUMBER: 496803065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This requirement is not met as evidenced by: LPA observed that two fire extiguishers were expired, dated 8/2/21. Resident rm 5 exit slider door is blocked by a tall feeding tray on wheels, a stick in the slider track which doesn't allow the door to fully open, a large hoyer lift machine on the outside of the slider door-in front of it.-all blocking exit from this door.
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The facilty garage is being used as a sleepin room for staff; Staff 4 has their personal belongings, clothes, shoes, bed, blankets, dressers, numerous medications, and medication supplies in the garage.
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Submit plan of correction by 10/20/22 on getting the fire extinguishers serviced and tagged annuallynas required, and on getting them serviced/tagged by 10/26 as required by the citation.
Type A
10/20/2022
Section Cited

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87465(h)(2) Incidental Medical and Dental Care- The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication
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This requirement was not met as evidenced by: LPA observing several medications in an unlocked small refrigerator, 3 medications found in a residents room, several medicaions found in the kithen, numerous mediction found in the garage, all these medications were not locked up as required by law which left them accessible to residents in care. This is a risk to health & Safety and/or personal rights risk to residents in care.
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 and review medication policies and procedure regarding storage of medications in compliance with regulations. Submit plan of correction by 10/20/22.
Follow-up with proof of training by 10/25/22-
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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/19/2022 04:03 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: MAEGAN'S CARE HOME
FACILITY NUMBER: 496803065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/20/2022
Section Cited

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Care of Persons with Dementia 87705 (f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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This requirement was not met as evidenced by: LPA observed a large pile of tools and misc items on the floor to the left side as they stepped outside the door leading to the backyard. This is a risk to health & Safety and/or personal rights risk to residents in care.
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Submit plan of correction by 10/20/22, and submit how this was corrected and plan for future complaince.
Type B
10/26/2022
Section Cited

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Plan of Operation-Each facility shall have and maintain a current, written definitive plan of operation. Any significant changes which would affect the services to residents shall be submitted to the licensing agency for approval. Revised sketch needed showing floor plan-Rm 4 is now a staff room, used by the Licensee/Spouse. Ialso nclude information requested by the form.
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 Please also submit the LIC200 application form completed, and showing new capacity of 4 residents- per facility floor plan review of today's inspection. POC due 10/27/22.
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receives the documents a fire clearancerequest will be sent as required. POC due 10/26/22.
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 DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022
LIC809 (FAS) - (06/04)
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