496803796-12-8-2022-21-AS-DALO-CLX36Y-20221208165908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803796
Report Date: 12/08/2022
Date Signed: 12/08/2022 04:59:19 PM

Document Has Been Signed on 12/08/2022 04:59 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:	WILLOW GLEN HOME		FACILITY NUMBER:	496803796
ADMINISTRATOR:	FLORES INEZ M.		FACILITY TYPE:	740
ADDRESS:	4750 COUNTRY CLUB DR		TELEPHONE:	(707) 708-2199
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	6	CENSUS: 6	DATE:	12/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Administrator Inez Florez,		TIME COMPLETED:	05:00 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	Licensing Program Analyst (LPA) Dina Alviso conducted Required 1-Year inspection and met with Administrator Inez Florez, and Licensee Zoe Teeter. Upon LPA's arrival there was one caregiver Rosa Orantes on shift. Caregiver contacted the Licensee Zoe Teeter, who arrived to the facility with the Administrator a short time later. The inspection is focused on the Infection Control procedures and practices of this facility. Residents are screened daily, and observed for any changes, all information is logged. Facility was found to be clean, and at a comfortable temperature with all exits free from obstruction. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored in a closet, locked and making them inaccessible to residents and staff that do not handle medications. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Administrator and the staff on duty all had masks on during the LPA's inspection. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Licensee has submitted the Infection Control Plan to the Licensing office as required. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden; There were six (6) residents in care at the facility during this inspection. Toxins are stored in a closet that was open, leaving toxins/cleaners accessible to residents in care. This deficiency will be cited, 87705 (f)(2)locked cabinets. 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: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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 12/08/2022 04:59 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: WILLOW GLEN HOME	FACILITY NUMBER: 496803796
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: LPA's observations during the inspection.
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above in locking and securing toxins/cleaners as required by regulation. LPA observed toxins/cleaners in an open closet, making them accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure all toxins/cleaners are locked and secured per regulations, ensuring these items are not accessible to residents in care. Licensee to submit in-service to all staff regarding the storing of cleaning supplies per regulations. Training proof,date/time spent, topics, attendees, and trainer, to be submitted by 12/16/2022. Plan of correction to be submitted by 12/9/22.

Type A

Section Cited

CCR

87705(j)

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onLPA's observation of the alarm turned off on kitchen door that leads into the garage. There are two steps that lead into the garage from this door, and the garage door to the outside was open and leading to the sidewalk and street .which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/09/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure that all staff keep all the auditory alarms turned on as needed per the residents in care and per the dementia care plan of the facility. Licensee/ Administrator to hold an inservice with all staff regarding the dementia care plan and the auditory devices on all exits, procedures of the facility. Submit proof of training, Date/Time, Topics, Trainer, attendees, by 12/16/22, Plan of correction due 12/9/2022.

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: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2022 04:59 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: WILLOW GLEN HOME	FACILITY NUMBER: 496803796
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (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: LPA's observations.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation during the inspection, LPA observed that the facility rug in all but one resident room, and in the hallway, the rug is lifting up in many areas, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/23/2022
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure the rug in the areas of the facility that are lifting up are repaired and/or rug replaced. Submit plan of correction fo the rug, and submit completion time frame for the correction. Submit photos and information on how the correction was made by 12/23/22. POC due 12/23/22.

Section Cited


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

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: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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: WILLOW GLEN HOME	FACILITY NUMBER: 496803796
	VISIT DATE: 12/08/2022

NARRATIVE

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The kitchen door leading into the garage had the alarm turned off, there are two steps leading down into the garage, and the garage door was fully open. Deficiency cited, 87705(j). The rug has many areas in the hallway, and in resident rooms where the rug is lifting up in walkways, which is a health and safety risk to residents in care. Deficiency cited, 87303(a). see LIC809D pages. The Licensee did clean the rugs since the LPA had discussed both concerns the last visit out to the facility. LPA obtained pictures of the deficiencies cited.

The following deficiencies were from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency(s) and/or repeat deficiencies within a 12 month period may result in civil penalties being assessed.

Exit interview conducted with the Administraor and the Licensee.
Appeal rights provided to the Licensee.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC809 (FAS) - (06/04)

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