496803849-6-18-2024-21-AS-CCOO-D6CQV6-20240618122948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803849
Report Date: 06/18/2024
Date Signed: 06/18/2024 12:30:02 PM

Document Has Been Signed on 06/18/2024 12:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	ADOM MANOR CARE HOME		FACILITY NUMBER:	496803849
ADMINISTRATOR:	KARIKARI, EVA		FACILITY TYPE:	740
ADDRESS:	2543 TACHEVAH DR		TELEPHONE:	(707) 526-6895
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY:	6	CENSUS: 5	DATE:	06/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Eva Karikari, Administrator		TIME COMPLETED:	12:44 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 (LPA) Christi Coppo and Jacky Macias arrived unannounced to conduct a required Annual inspection and was greeted by staff. Administrator Eva Karikari arrived shortly after. At approximately 09:30am LPAs and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink accessible to residents in care measured at 118, 113.2, 118.4, 119.4 and 118.5 degrees F which is within the allowable range of 105 to 120 degrees F. LPAs discussed with Admin about adjusting water heater temperature slightly as to avoid going over 120 degree threshold. Fire extinguishers were last inspected 5/15/2024. Smoke/Carbon Monoxide detectors located throughout the facility were present. Facility’s last quarterly disaster drills were conducted 4/12/2024. Facility has a backup generator for use during a power outage. At approximately 10:00am LPAs conducted review of 5 staff records. S2, S3, S4, S5 have did not have current annual training in the amount of hours required. S1 has no current First Aid/CPR Certification (deficiencies cited, see 809D). At approximately 11:00am LPAs conducted a review of 5 resident records. All required documentation present. Continued on 809C...

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ADOM MANOR CARE HOME	FACILITY NUMBER: 496803849
	VISIT DATE: 06/18/2024

NARRATIVE

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Continued from 809...

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies.

Administrator Eva Karikari 6046713740 Certificate expires 1/26/2024. Licensee/Admin provided proof of renewal payment. LPAs verified payment by viewing check issued.

LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

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

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/18/2024 12:30 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ADOM MANOR CARE HOME	FACILITY NUMBER: 496803849
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that S1 has no current First Aid/CPR Certification, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/02/2024
	Plan of Correction
1 2 3 4	Admin to submit to CCL photo of current First Aid/CPR certification by POC due date of 7/2/2024.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that S2, S3, S4, S5 did not have current annual training in the amount of hours required which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/09/2024
	Plan of Correction
1 2 3 4	Admin to submit to CCL photo of completed training certificates in the amount of hours required for S2, S3, S4, S5 by POC due date of 07/09/2024.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 06/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024

LIC809 (FAS) - (06/04)

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