Community Care Licensing

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having the laundry room unlocked which contains laundry detergent, disinfectant and bleach which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2021
	Plan of Correction
1 2 3 4	Licensee to submit self-certification indicating that they and their staff have reviewed regulation 87309 and will keep toxins inaccessible to residents by POC due date 10/7/2021.

Type A

Section Cited

CCR

87205(b)

(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above because their LLC has been suspended per the Secretary of State website which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2021
	Plan of Correction
1 2 3 4	Licensee to submit what they have done and what they are doing to make their LLC valid by POC due date, 10/7/2021.

SUPERVISOR'S NAME: Hope DeBenedetti TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Victoria Willis TELEPHONE: (707) 588-5087 LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021

Type A

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having brown lettuce, limp carrots and liquid pooling at the bottom of the refrigerator and freezer, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2021
	Plan of Correction
1 2 3 4	Licensee agrees to submit a picture to CCL showing that all food that has gone bad is removed from the refrigerator and freezer and that refrigerator and freezer is free from liquid pooling at the bottom by POC due date, 10/7/2021

Type A

Section Cited

CCR

87555(b)(23)

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above where four frozen items were not stored in containers made for freezing causing at least one to have freezer burn on it because the lid was not tight which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/07/2021
	Plan of Correction
1 2 3 4	Licensee agrees to submit self-certification that items stored in the freezer and refrigerator will be stored in appropriate containers by POC due date, 10/7/2021

SUPERVISOR'S NAME: Hope DeBenedetti TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Victoria Willis TELEPHONE: (707) 588-5087 LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as LPA observed what appeared to be rodent droppings on the outside deck and some deck boards still unsecured and cracked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Licensee agrees to make changes to the bird feeding schedule to deter rodents from coming onto the deck and will have boards secured and repaired by POC due date, 10/15/2021. LPA will return to observe repairs.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Hope DeBenedetti TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Victoria Willis TELEPHONE: (707) 588-5087 LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021

Type B

Section Cited

CCR

87506(b)(15)

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of five residents not having Admission Agreeements which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Licensee agrees to create/obtain signed Admission Agreements for R1 and R2 by POC due date, 10/15/2021. LPA will return to review records.

Type B

Section Cited

CCR

87456(a)(2)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of five residents does not have a Preplacement appraisail which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Licensee agrees to complete an updated Reappraisal for R3 POC due date, 10/15/2021. LPA will return to review records.

SUPERVISOR'S NAME: Hope DeBenedetti TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Victoria Willis TELEPHONE: (707) 588-5087 LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021

Type B

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of five residents not having a Medical Assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Licensee agrees and Physician's Report for R2 by POC due date, 10/15/2021. LPA will return to review records.

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of five residents not having updated appraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2021
	Plan of Correction
1 2 3 4	Licensee agrees to complete reappraisals for R1, R3 and R4 by POC due date, 10/15/2021. LPA will return to review records.

SUPERVISOR'S NAME: Hope DeBenedetti TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Victoria Willis TELEPHONE: (707) 588-5087 LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021

Type B

Section Cited

HSC

1569.695(b)

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of one staff not having documented training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	Licensee to document disaster and emergency training and retain in staff file by POC due date, 10/11/2021. LPA will return to review records.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Hope DeBenedetti TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Victoria Willis TELEPHONE: (707) 588-5087 LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021

Type B

Section Cited

CCR

87705(c)(3)(A)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of one staff not having any documented training hours which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff are trained per regulation by POC due date, 10/22/2021. LPA will return to review records.

Type B

Section Cited

HSC

1569.625(b)

(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hrs of training. A staff member shall complete 20 hrs, including 6 hrs specific to dementia care and 4 hrs specific to postural supports, restricted health conditions, and hospice care before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one out of one staff not having initial training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff are trained per regulation by POC due date, 10/22/2021. LPA will return to review records.

SUPERVISOR'S NAME: Hope DeBenedetti TELEPHONE: (707) 588-5059 LICENSING EVALUATOR NAME: Victoria Willis TELEPHONE: (707) 588-5087 LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021