496803311-3-28-2024-21-AS-DALO-D3T2QR-20240328173623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803311
Report Date: 03/28/2024
Date Signed: 03/28/2024 05:36:33 PM

Document Has Been Signed on 03/28/2024 05:36 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: 5	DATE:	03/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Mera Shaughnessey-Administrator		TIME COMPLETED:	05:50 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 3/28/24 at approximately 12:40pm, and met with Licensee/Administrator Mera Shaughnessey. There currently are five (5) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three(3)residents. Facility has a required infection control plan. Facility has an emergency and disaster plan as required. The facility conducted a fire drill and earthquake drill on 1/5/24. Facility does have a generator for emergencies if needed. The facility does have emergency food, water, and supplies to meet the "72 hour shelter in place" requirements. LPA reviewed five (5) resident files. All files were complete. The LPA reviewed five (5) staff files. All staff have criminal record clearance. All staff have current first aid and CPR certification as required. The LPA toured the facility with the Administrator Mera. The hot water was checked at 117. degrees Fahrenheit , which is within regulation. The fire extinguishers were tagged and serviced as required-expires 12/28/24. All exits were unobstructed. Food supply was sufficient. All bathrooms have grab bars, and the large shower room and private shower bathrooms have mats for resident use. The facility is well lighted, including all resident rooms and bathrooms. The facility was observed to be warm and at a comfortable temperature. Cleaners/toxins were locked and inaccessible to residents in care. All medications were locked up and not accessible to residents in care. Facility had sufficient furnishings for client use. 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: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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: 03/28/2024

NARRATIVE

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LPA is requesting the following documents be updated and submitted by 4/28/24.
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.

The following deficiencies were observed during staff file reviews:

Four (4) out of five (5) staff lacked annual required training hours, per LPA's file reviews. This deficiency will be cited, HSC 1569.696(b)(2) 2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training, see LIC809D.

Four (4) out of five (5) staff lacked required Health and Safety Code annual medication training, per LPA's file reviews. This deficiency will be cited, 1569.69(b)Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period, see LIC809D.

Deficiencies 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 with Administrator/Licensee Mera Shaughnessey.
Appeal Rights provided to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2024 05:36 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: PLATINUM RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803311
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(b)

1569.69(b)Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Four (4) staff lack proof of required HSC 1569.69(b) medication training, per LPA's file reviews, the licensee did not comply with the section cited above in four out of five file reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/16/2024
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff obtain the H&S Code annual medication training as required; Submit proof of the staffs, four (4), medication training by POC due date of 4/16/24.

Type B

Section Cited

HSC

1569.696(b)(2)

In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Four (4) staff lack proof of required annual training, per LPA's file reviews, the licensee did not comply with the section cited above in [four] out of [five) file reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/16/2024
	Plan of Correction
1 2 3 4	Licensee to ensure all four direct care staff obtain required annual training; Submit proof of training by POC due date of 4/16/24.

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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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