496803311-4-20-2023-21-AS-DALO-CR42BS-20230420171535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803311
Report Date: 04/20/2023
Date Signed: 04/20/2023 05:15:47 PM

Document Has Been Signed on 04/20/2023 05:15 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:	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: 6	DATE:	04/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	Tosha Sisneros-Administrator		TIME COMPLETED:	05:20 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) Alviso conducted a Required- 1 Year visit, on 4/20/23 at approximately 12:16pm, and met with Licensee/Administrator Mera Shaughnessey, and Administrator Tosha Sisneros. There are currently six(6) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three(3)residents. Facility submitted the required infection control plan. Facility has an emergency and disaster plan as required. The facility conducted a fire drill and an earthquake emergency drill on 1/5/2023. Facility does have a generator for emergencies if needed. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Fire clearance is approved for six (6) non-ambulatory/bedridden residents, effective 9/10/2020. Al exits were free and clear of obstruction. Fire extinguishers, two(2), were serviced and tagged as required, expires 2/6/2024. LPA observed eleven(11) of eleven(11) smoke alarms, smoke alarm system is also a carbon monoxide detector, the smoke alarm system was working properly during the inspection. All exit doors had auditory alarms and the alarms were working properly during the inspection. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Hot water was checked at 116.F which is within regulation. Medications were stored and locked making them inaccessible to residents. All toxins and cleaners were stored in locked cabinets, and inaccessible to residents in care. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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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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: PLATINUM RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803311
	VISIT DATE: 04/20/2023

NARRATIVE

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There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable.

There are six(6) residents in care. LPA reviewed six(6) of six(6) resident files; All resident files were found to be complete.

LPA reviewed five(5) of five(5) staff files. LPA reviewed staff training. All five(5) staff have criminal record clearance, and are associated as required. All staff had required annual training. All staff had current First Aid and CPR Certification.

LPA is requesting the following documents be updated and submitted by 5/5/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required)
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond.
Copy of Current Liability Insurance
Copy of current Administrator Certificate

No deficiencies cited today.
Exit interview conducted with Licensee Mera Shaughnessey, and Administrator Tosha Sisneros.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC809 (FAS) - (06/04)

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