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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803537
Report Date: 01/31/2023
Date Signed: 01/31/2023 10:48:26 AM


Document Has Been Signed on 01/31/2023 10:48 AM - 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:KENWOOD GREENSFACILITY NUMBER:
496803537
ADMINISTRATOR:VEGVARY, JULIUSFACILITY TYPE:
740
ADDRESS:340 GREENE STREETTELEPHONE:
(707) 483-0998
CITY:KENWOODSTATE: CAZIP CODE:
95452
CAPACITY:8CENSUS: 4DATE:
01/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mercedes VegvaryTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst Leibert arrived unannounced for the purpose of following up on additional information obtained subsequent to findings made on a complaint received on July21, 2022 and closed on September 22, 2022 as Unsubstantiated. Further review of statements and recently acquired medical records indicate that facility staff noted a sore on R1 on 7/12/2022; that the Administrator requested a nurse visit and Hospice Care for R1 on 7/13/2022; Hospice was approved but due to staff issues and/or, Covid outbreaks or other unidentified reasons, Hospice was not able to do an assessment timely. Medical attention for R1 was not provided until R1 was sent out for treatment on 7/20/20. Upon admittance to medical facility, R1 was diagnosed with stage ll/III pressure injuries.


The following deficiencies were observed (see LIC 9099D) 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.

Report left at facility.

SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/31/2023 10:48 AM - 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: KENWOOD GREENS
FACILITY NUMBER: 496803537

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited

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87465(a)(1) INCIDENTAL MEDICAL AND DENTAL CARE. The Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of the residents. ***Based upon statements and document reviews, this requirement has not been met as evidenced by: R1, malnourished and in
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Administrator shall perform an in-service with her staff to ensure that residents with wounds receive timely home health or Hospice Care and, if not available, that residents are seen by a physician. Proof of training will be provided to CCL by POC date in order to clear the deficiency.
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frail condition, presented with a sore on 7/12/2022 which prompted the Administrator to request nursing or Hospice care for R1 on 7/13/2022 which did not occur. R1 was not sent out for medical treatment until 7/20/2022 when diagnosed with stage ll and unstageable pressure injuries. * This posed an immediate risk to the health of R1.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
LIC809 (FAS) - (06/04)
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