496803311-9-25-2020-21-AS-DALO-BTSSQ7-20200925140416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803311
Report Date: 09/25/2020
Date Signed: 09/25/2020 02:04:47 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:	PLATINUM RESIDENTIAL CARE HOME		FACILITY NUMBER:	496803311
ADMINISTRATOR:	SISNEROS, TOSHA		FACILITY TYPE:	740
ADDRESS:	1972 DENNIS LANE		TELEPHONE:	(707) 757-8607
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 0	DATE:	09/25/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Mera Khiroya Shaughnessy-Licensee		TIME COMPLETED:	12:15 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), Dina Alviso, conducted a televideo case management inspection, and met with Licensee Mera Shaughnessy on 9/25/20 at approximately 11:35AM. This inspection is being conducted by televideo due to the covid 19 pandemic. Reader is advised that the LPA did not make a site visit. Facility burned down during the Santa Rosa wild fires of 10/2017. Facility has completed the rebuild and is wanting to re-open. Santa Rosa Fire Department approved the fire clearance for 6 nonambulatory/bedridden capacity-effective 9/10/20. The large master bedroom may accommodate two residents but facility is to not exceed 6 residents at anyone time. Facility is approved to care for dementia residents. Facility has a hospice waiver approved for three (3). Hot water was observed to check at 111 F, which is within regulation. All exits were unobstructed. All exit doors had working auditory alarms. Facility's fire alarm system is hard wired and includes carbon monoxide detection. The fire alarm and carbon monoxide system was observed to be working properly during the inspection-system verbally states all information. The facility had two fire extinguishers hanging for emergency use as needed. There is a call system in place for residents to use as needed, to alert staff of needed assistance and/or in an emergency situation. All rooms are private, and have a private half bathroom. The facility has a large shower room/bathroom for all residents to use. All rooms have the space to accommodate all furnishings and items per regulations. Facility has a large yard with clear walkways for resident use. Patio furnishings are provided for resident use. Continued on LIC809C..

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PLATINUM RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803311
	VISIT DATE: 09/25/2020

NARRATIVE

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Facility has emergency supplies in place, including water. Facility has PPE supply. Facility has all required posting up in the front of the house, in the home, including in all bathrooms. LPA discussed staff screening before entering for staff shift, temperature taking, screening questions, and logging of all information. LPA discussed the mandated order of all staff wearing masks at all times. Discussed taking temperatures of residents in care, logging information, disinfecting all items /areas of the facility at least once a day and as needed. Licensee stated that she understood all the above and will ensure compliance with these items.

Licensee has submitted the updated emergency plan of the facility, including the Covid 19 pandemic policies.Licensee has submitted other updated documents such as the admission agreement to the Licensing office. Licensee stated that she will submit the facility's current liability insurance before admitting any residents into care. LPA observed no health and safety hazards during the televideo inspection.

Licensee will sign the report LIC809/809C and return a copy to the LPA as discussed.

Repopulation of the facility residents is approved today, 9/25/20.

No deficiencies cited.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020

LIC809 (FAS) - (06/04)

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