<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803828
Report Date: 06/24/2021
Date Signed: 06/24/2021 01:53:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:RINCON VALLEY GUEST HOMEFACILITY NUMBER:
496803828
ADMINISTRATOR:POPAT, SABRINAFACILITY TYPE:
740
ADDRESS:996 ESTES DRTELEPHONE:
(707) 539-6247
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 5DATE:
06/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Caregiver Marlene GuidoTIME COMPLETED:
02:05 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 Analysts (LPAs) Lopez and Cuadra arrived unannounced to conduct an Annual Required inspection and met with caregiver Marlene Guido. Licensee, Sabrina Popat was not present during the visit but was available by phone and gave authorization to caregiver to sign the report. The inspection is focused on the Infection Control procedures and practices of this facility. LPAs conducted a Risk Assessment call with Licensee Sabrina Popat, prior to visit.

LPAs arrived at the facility and had their temperature checked and logged into a sheet of paper. During facility tour with caregiver; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. During the tour LPAs/staff observed scissors unlocked in the drawer and medication cart was unlocked and accessible to residents in care. A technical advisory was issued due to new addition to the facility, a room with a bathroom was installed between the garage and patio. Per staff, the construction was done around April 2021 and Licensee did not notify CCL about it. Licensee was contacted and agreed to submit a new facility sketch and is aware that a new fire clearance approval needs to be submitted to CCL prior to move-in residents.

Facility has submitted a mitigation program plan. Posters were placed at the entrance. LPAs observed Covid-19 related posters in resident's bathrooms that included hand-washing signs. Facility checks the temperature of visitors, asks them screening questions and documented into a sign-in sheet. LPA was informed that facility is conducting surveillance testing weekly to 25% of staff. LPA confirmed that facility is checking resident and staff temperatures daily and the information is being documented. Staff had masks on during this visit. Facility staff have had PPE training and have been N-95 Fit tested. Facility has PPE supplies. Residents do not typically wear masks inside the facility but have them available. Residents do however, wear masks while away from the facility.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: RINCON VALLEY GUEST HOME
FACILITY NUMBER: 496803828
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(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:
Deficient Practice Statement
1
2
3
4
Based on LPAs/staff observation and interview, the licensee did not ensured to keep scissors unlocked in a drawer, alcohol in resident's room and medication cart unlocked accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/25/2021
Plan of Correction
1
2
3
4
Licensee to ensure that toxins, sharp objects and medications are inaccessible at all times to residents in care. Licensee to remove and lock all medications and toxins through the facility by POC due date of 6/25/21. Licensee agrees to submit to CCL an LIC9098 self-certification that all medications & toxins for residents are locked through the facility by POC due date of 6/25/21.
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3