496803807-3-16-2023-21-AS-DALO-CNKU6V-20230130141858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803807
Report Date: 01/30/2023
Date Signed: 03/16/2023 06:18:01 PM

Document Has Been Signed on 03/16/2023 06:18 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/15/2023 03:26 PM

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

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	"AMENDED' .. This is an amended version of the original report created on 1/30/23-SEE PG 2. Licensing Program Analyst (LPA) Alviso conducted a Required 1-Year visit, and met with Jose Acumabig, Administrator. The inspection is focused on the Infection Control procedures and practices of this facility. The facility has submitted the required" Infection Control Plan" to the Licensing Office, it's part of the facility's "Plan of Operation." All visitors are screened upon entering the building; All visitors have their temperatures taken and information is logged. Residents are screened daily, and observed for any changes, including a temperature check. All staff are screened before each shift, including temperatures taken, all information is logged. Currently twenty-five(25) residents in care, and one(1)resident receiving hospice care. Hospice care waiver is approved for ten(10) residents. The facility does not have a dementia plan of operation. Fire clearance approval is for forty-five (45) non-ambulatory. All exits were observed by the LPA to be free from obstruction. The facility fire extinguishers were serviced and tagged as required- expires 4/5/23. The two kitchen fire extinguishers were tagged-expires 1/2024. Facility offers activities during the day for those wanting to participate. The facility has a sufficient supply of personal protective equipment (PPE). Bathrooms observed had grab bars, and non-slip mat/flooring for bathing as needed. All postings were up and visible to all as required. LPA observed all staff wearing masks as required during LPA's inspection. Continued on LIC809C...

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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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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: COGIR OF ROHNERT PARK	FACILITY NUMBER: 496803807
	VISIT DATE: 01/30/2023

NARRATIVE

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All medications were locked up in the medication room, making them inaccessible to residents in care. All toxins/cleaners were locked up, making them inaccessible to residents in care.

"AMENDED" The LPA toured the kitchen with the Administrator. Between approximately 10:35 am and 11:00 am, LPA and Administrator observed several plated bowls of fruit unattended in the dining room sitting out improperly covered/exposed on a service cart, observed lettuce and mayonnaise on the salad bar table in the kitchen and open commercial size bag of rice and commercial size box of beans open on the kitchen/pantry floor with no means to close the packages in order to prevent them from potential contamination. LPA was unable to verify how long trays of food and salad bar items had been improperly stored. The Administrator agreed with food storage concerns, and started working with the kitchen staff on a plan of correction during LPA's inspection. LPA obtained pictures for the file. The deficiency will be cited, General Food Service Requirements 87555(b)(9)-see LIC809D.

The following deficiencies were observed (see LIC 809D) 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 with the Administrator. Appeal rights provided.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2023 02:19 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: COGIR OF ROHNERT PARK	FACILITY NUMBER: 496803807
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87555(b)(9)

General Food Service Requirements 87555(b)(9) The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, during tour of the kitchen with the Administrator,the facility did not ensure that fruit, mayonnaise, an open box of beans, and open bags of rice were stored appropriately to protect the safety and acceptability necessary to prevent contamination, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2023
	Plan of Correction
1 2 3 4	Facility to hold an in-service training with all kitchen staff regarding facility’s storage of food, food preparation, and food services. Submit plan of correction in how the facility will correct the deficiency, and the plan to hold an in-service training with staff. Proof of training to, include trainer, topics, date, time spent, attendees, and employee signatures. Submit proof of training by 2/6/23. Submit plan of correction by 1/31/23.

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: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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