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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803731
Report Date: 04/28/2023
Date Signed: 04/28/2023 02:59:16 PM


Document Has Been Signed on 04/28/2023 02:59 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:LAS PALMAS ASSISTED LIVINGFACILITY NUMBER:
496803731
ADMINISTRATOR:PRICE, THOMASFACILITY TYPE:
740
ADDRESS:218 N HIGH STREETTELEPHONE:
(707) 583-5895
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY:6CENSUS: 5DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Josephine Blancaflor (Licensee)TIME COMPLETED:
03:14 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with Licensee Josephine Blancaflor. There are residents with a diagnosis of dementia or hospice.

LPA/Licensee initiated a tour of the facility and made the following observations: facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closets. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked in medication cabinet. Smoke/Carbon Monoxide detectors located throughout the facility that were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Medications and medication records were reviewed. Fire/disaster drill has been conducted in January 2023. Three staff files and five resident files were reviewed. Staff does have current required First Aid, CPR certificates and annual required training hours. All residents have their medical assessment and care plans updated within the last 12 months. Administrator and LPA discussed their Emergency Disaster Plan and Infection Control Plan. Administrator Certificate for Administrator, Josephine Blancaflor #6015304740 expires 7/14/2024. Required postings were observed. Water temperature in resident bathroom measured 110.8 degrees F which are within allowable range of 105 to 120 degrees F.
At approximate 1:00pm LPA/Licensee observed two out of two fire extinguisher were last inspected August, 2021. Licensee called immediately Sebastopol Fire Department to have them come and service them.

Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308) and Personnel Report (LIC500) and a copy of Liability Insurance.

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. Appeal rights given. Exit interview conducted with Licensee.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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Document Has Been Signed on 04/28/2023 02:59 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: LAS PALMAS ASSISTED LIVING
FACILITY NUMBER: 496803731

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the facility did not comply with the section cited above in 2 out of 2 fire extinguishers had not been serviced since August 2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2023
Plan of Correction
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Administrator contacted the Fire Department to have fire extinguisher serviced. Administrator agreed to submit self-certification form as a proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
LIC809 (FAS) - (06/04)
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