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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803071
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:58:51 PM


Document Has Been Signed on 11/28/2023 02:58 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:BURBANK MANORFACILITY NUMBER:
496803071
ADMINISTRATOR:GREGORIO, ARLINDAFACILITY TYPE:
740
ADDRESS:612 HENDLEY STREETTELEPHONE:
(707) 542-2065
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:6CENSUS: 6DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Arlinda Gregorio, LIcensee/AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen, arrived unannounced to conduct an Annual Required Inspection and met with Caregiver, Judith Gonzales. Licensee, Arlinda Gregorio arrived later. Per staff, the facility has four residents on hospice which is allowable per the facility Hospice Waiver, with one exception. There were three staff providing care and supervision to six residents. There are 2 residents currently with a diagnostic of dementia.

LPA initiated a tour of the facility at 8:30 AM and made the following observations: Facility was a comfortable temperature with thermostat in hallway reading at 72 degrees F. Passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident bathrooms measured at 110.6 and 112.6 degrees F, within allowable range of 105 to 120 degrees F in bathroom faucets residents use. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Kitchen cabinets containing cleaning supplies were locked; although cabinet in laundry with disinfectant supplies was unlocked and Lysol disinfectant was in both bathrooms, accessible to residents in care (see LIC 809-D). Bathrooms also contained cloth, face, hand, and body towels that are now not to be commingled with other residents (see TV9102). Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected 9/15 2023. Smoke detectors located throughout the facility and the Carbon Monoxide detector were tested and operational. Exit doors have auditory alerts that were functional at time of visit.

File review was initiated at 10:50 AM. Five staff files and six resident files were reviewed. One out of five staff did not have required First Aid and CPR certificates, but completed by end of Annual Inspection. Administrator Certificate for Licensee/Administrator, Arlinda Gregorio 6009780740, expired per Administrator 10/3/2021 and is in the process of recertification (see LIC809-D). Medications and medication records were reviewed. Training records for 2 of 5 staff records reviewed were not up to date per regulations (see TV LIC9102). Required postings were observed.

Continued on LIC809C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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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Document Has Been Signed on 11/28/2023 02:58 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: BURBANK MANOR
FACILITY NUMBER: 496803071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

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
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Based on observatio, the licensee did not comply with the section cited above in 3 out of 3 disinfectants were available to clients in care (2 bathrooms Lysole) and cleaning supply cabinet unlocked in laundry room, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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Licensee to discuss regulation with staff, submit acknoledgement of understanding of regulation with signed & dated staff to CCL by 11/29/2023 to clear POC.
Type A
Section Cited
CCR
87405(a)

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.
This requirement has not been met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, and interview the Licensee/Administrator did not comply with this section above due to Licensee's Administrators Certificate expired 10/3/2021. Although another staff has current Administrator certificate, they are not the Administraor and have not been present full time since 10/3/2021.Licensee claimed all items were submitted for renewal of administrator certificate but after calling while LPA was at facility found out from Administrator certificate unit, certificate is not pending or active. This regulation poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/29/2023
Plan of Correction
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Licensee to obtain actual certificate and submit to CCL proof of submission. During time, Licensee to ensure interim certified Administrator is on site while Licensee is renewing certificate. Copy of Personnel Summary outlining administrator's hours to be submitted to CCL by POC due date of 12/5/2023. Licensee to submit Administraotr Certificate to CCL when obtained.
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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 9


Document Has Been Signed on 11/28/2023 02:58 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: BURBANK MANOR
FACILITY NUMBER: 496803071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
(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
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Based on record review, the licensee did not comply with the section cited above in 4 out of 6 resident files did not have reappraisals conducted in the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Plan of Correction (POC) shall include that ALL residents have Reappraisals performed in accordance with regulation. Furthermore, Licensee shall conduct staff training on reappraisals and a plan for future compliance. Submission of plan for future compliance and 4 reappraisals to be submitted to CCL by POC due date of 12/5/2023
Type B
Section Cited
CCR
87411(c)(1)
87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. 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
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Based on interview & record review, the licensee did not comply with the section cited above in 1 out of 4 staff records reviewed did not have current required First Aid Certificate on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/05/2023
Plan of Correction
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Licensee/Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC cleared at visit.
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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 7 of 9


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: BURBANK MANOR
FACILITY NUMBER: 496803071
VISIT DATE: 11/28/2023
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Continued from LIC809

At approximately 1:30PM, LPA reviewed 6 resident records and found 6 of 6 residents to have current physician's reports, signed admission agreements, although Reappraisals & care plans of 4 out of 6 residents were not current or did not exist (see LIC809-D).

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Administrator informed Disaster Drills are conducted quarterly with the last disaster drill being conducted on 9/1/2023.

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.


LPA Hansen is requesting facility to submit the following documents to CCL by 12/19/2023:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Copy of Current Administrators Certificate
Copy of Control of Property Recent updated Lease
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
Page: 9 of 9