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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803832
Report Date: 11/30/2023
Date Signed: 11/30/2023 03:16:28 PM

Document Has Been Signed on 11/30/2023 03:16 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:CALIFORNIA MENTOR-CALISTOGA HOMEFACILITY NUMBER:
496803832
ADMINISTRATOR:SARAH LUCASFACILITY TYPE:
735
ADDRESS:5302 BADGER RDTELEPHONE:
(707) 538-9684
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 4CENSUS: 4DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maureen Bleck (Nursing Supervisor)TIME COMPLETED:
03:31 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of conducting an Annual required inspection and met with Maureen Bleck Nursing Supervisor. Administrator Sarah Lucas was not able to come to the facility, but was available by phone and gave authorization for staff to sign the report. There are currently 4 clients in care.

LPA initiated tour of the facility at 11:00am: The facility was a comfortable temperature, free from obstructions. and was well lit. Extra hygiene products and linens were available. Water temperature in resident's bathrooms measured at 109.3 and 112.3 degrees F which is within acceptable range of 105 to 120 degrees F. Cleaning products will be located in a locked cabinet in the garage. Perishable and non-perishable foods were found to be stored in a safe manner and met the required minimum with a 7 day supply of non-perishable foods and 2 day supply perishable foods. 3 of 4 clients are currently on liquid diets via G-Tubes. All areas are able to accommodate wheel chair access. Facility has fire sprinklers throughout which was tested by Santa Rosa Fire Equipment January 2023. Fire Detectors are hardwired and facility has a fire pull station which activates sound and light devices on the ceiling. Fire extinguisher inspected was charged October 2023. Carbon Monoxide detector was located in the hallway. Facility does have a portable generator in the event power is disrupted. Facility have a nurse (2 LVNs) 8 hours a day to oversee medical needs and medication. An RN is available on-call at all times. Medications are stored in a locking medication cart located off the living room. Medications and medication records were reviewed. LPA observed van to be used for transportation. Facility maintains a maintenance binder for review. P&I monies is documented, secure and not commingled.

At approximate 11:15am Per Administrator, the last disaster drill was conducted on April 2023.

Continue on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: CALIFORNIA MENTOR-CALISTOGA HOME
FACILITY NUMBER: 496803832
VISIT DATE: 11/30/2023
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At approximate 11:20am: LPA/staff observed full bed rails being used on 3 of 4 beds. Based on interviews with Administrator, the facility has not requested exceptions for full bed rails and G-Tube exceptions from the Department as instructed during Pre-licensing visit on 9/3/19 for 3 of 4 clients (C1, C2 & C3). 1 of 4 clients do not have exception on file for wheelchair postural support on file. Administrator agreed to submit pertinent documents to CCL for review by not later than 12/14/23. There is an exception on file for administration of PRN. A technical advisory will be issued.

At approximate 12:00pm LPA conducted file review. A review of client records revealed Admissions Agreements missing for 4 of 4 clients. Per Administrator, client's records do not contain Admissions Agreements and Medical Assessments. During today's visit, LPA was provided with all clients Needs/Service Plans. Administrator Certificate for Administrator Sarah Lucas 6060043735 expired on 6/23/23. All staff have current CPR/1st aid. However, Administrator was unable to provide proof of training for staff (S1, S2, S3 & S4). All staff, including skilled professionals will need updated training not limited to the following areas: Gastronomy Feeding, Hydration and Care 80092.10, Colostomy Care, Medications and Restricted Health Conditions.

Administrator agrees to submit the following documents by 12/14/23:



LIC 308 Designation of Administrative Responsibility.
LIC 500 Personnel Summary.
LIC 400 Affidavit Regarding Resident Cash Resources.
LIC 402 Surety Bond.
Evidence of Liability Insurance.

Deficiencies cited from the California Code of Regulations, Title 22 of the California Regulations and Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator who acknowledged citations issued and copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/30/2023 03:16 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/30/2023 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CALIFORNIA MENTOR-CALISTOGA HOME
FACILITY NUMBER: 496803832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 4 client's admission agreements were not on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator will ensure that client's have an individual written admission agreement on file, and will submit LIC9098 self-certification form to CCL by POC due date to clear the citation. LPA will return to review files.
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, interview and record review, the licensee did not comply with the section cited above in 4 out of 4 clients do not have a current medical assessment on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator will ensure that client's have a curret medical assessment on file, and will submit LIC9098 self-certification form to CCL by POC due date to clear the citation. LPA will return to review files.
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 Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/30/2023 03:16 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/30/2023 at 02:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CALIFORNIA MENTOR-CALISTOGA HOME
FACILITY NUMBER: 496803832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80092.1(g)
General Requirements for Restricted Health Conditions
(g) All new facility staff who will participate in meeting the client's specialized care needs shall complete the training prior to providing services to the client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records revie and interview with Administrator, the licensee did not comply with the section cited above in 4 out of 4 staff have not completed the training prior to provide services to clients in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Administrator to ensure all staff including skilled professionals will complete updated training not limited to the following areas: Gastronomy Feeding, Hydration and Care 80092.10, Colostomy Care, Medications and Restricted Health Conditions by POC due date to clear the deficiency. Administrator will submit a self-certification LIC9098 form to CCL as proof of completion. LPA will return to review files.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with Administrator, the licensee have not conducted a disaster drill since April 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Facility will conduct a disaster drill by POC due date. Administrator will submit a self-certification LIC9098 form to CCL as proof of completion.
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 Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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