496803379-2-6-2024-21-AS-SHAN-D27TM3-20240206135029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803379
Report Date: 02/06/2024
Date Signed: 02/06/2024 01:50:34 PM

Document Has Been Signed on 02/06/2024 01:50 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:	HILL TERRACE		FACILITY NUMBER:	496803379
ADMINISTRATOR:	CASTANEDA, RAMIRO ERNESTO		FACILITY TYPE:	740
ADDRESS:	922 COTTONWOOD COURT		TELEPHONE:	(707) 981-7784
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	5	CENSUS: 1	DATE:	02/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:26 AM
MET WITH:	Kevin Castaneda, Licensee		TIME COMPLETED:	02:00 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	License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct an annual required visit of the facility. LPA was welcomed by and met with Licensee Kevin Castaneda. There is a total of 1 resident, no dementia residents. LPA toured the facility on 2/6/2024 at 10:00 AM with Licensee Kevin Castaneda; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices; all auditory devices were working properly. Smoke detectors and carbon monoxide detectors were found to be operational during the visit. Hot water temperature measured 116.7 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in resident’s bathroom while touring facility on 2/6/2024. The facility serves residents with dementia and has a plan of operation for special care and programming. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry room/garage. Dangerous items were found stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for resident. The bathroom designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s bed was outfitted with mattress pad as required by Title 22 Regulations # 87307 on 2/6/2024 at 10:30 AM. A review of one resident & two staff records was conducted. LPA reviewed resident’s files at 11:45 AM on 2/6/2024 and learned that 1 of 1 residents have an updated re-appraisals/needs & care plans and physician’s assessments (LIC 602A) are updated as required by Title 22 Regulations on file. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

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: HILL TERRACE	FACILITY NUMBER: 496803379
	VISIT DATE: 02/06/2024

NARRATIVE

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Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.”

Medications were centrally stored in locked cabinet in the facility kitchen. The Medications of 1 out of 1 residents were found to be given according to physicians’ directions on 2/6/2024. Centrally Stored Medication Record (CSMR) of 1 out of 1 residents were found to be complete and accurate.

LPA reviewed a sample of staff records on 2/6/2024 and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. LPA observed during staff file review that facility has required trainings. LPA was presented with proof of CPR & 1^st Aid certification for staff that files were reviewed. Ramiro Castaneda Administrator Certificate # 6015597740 expires on 4/21/2024. Disaster Drills have been conducted quarterly with the last one being conducted 10/2023.

LPA reviewed Licensing Information System (LIS) with licensee 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.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update the following documents by 2/20/2024:
LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2024

LIC809 (FAS) - (06/04)

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