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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803853
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:55:36 PM

Document Has Been Signed on 03/09/2023 04:55 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:MOGRACE RESIDENCEFACILITY NUMBER:
496803853
ADMINISTRATOR:GACEGU, MONICAHFACILITY TYPE:
740
ADDRESS:6299 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7884
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 8CENSUS: 5DATE:
03/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Alice Wanjirn-CaregiverTIME COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst(LPA) conducting a case management visit, at approximately 4:00pm on 3/9/23, and met with Caregiver Alice; There are currently five residents in care.

This case management is being conducted to address two deficiencies found during the complaint visit of earlier today. The deficiencies are unrelated to the complaint investigation.

LPA observed that a resident's(R2) room in the back of the home smelled of very strong urine odor, the resident is incontinent, the odor of urine the LPA could smell as they entered the home. LPA observed that the residents room needs to be cleaned and free from the urine odor, and the facility's other areas need to be free from the urine odor. This deficiency will be cited, Managed Incontinence (b)(3)-see LIC809D.

LPA observed that there was medication bottle on the residents night stand, the medication is not centrally stored as required. This deficiency will be cited, Incidental Medical & Dental Care 87465(h)(2)-see LIC809D.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies as required may lead to additional citations and civil penalties, including deficiencies re-cited within 12 months.
Exit interview conducted.
Appeal Rights Given to Alice Wanjirn-Caregiver
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2023
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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Document Has Been Signed on 03/09/2023 04:55 PM - It Cannot Be Edited


Created By: Dina Alviso On 03/09/2023 at 04:22 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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2023
Section Cited
CCR
87465(h)(2)

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87465(h)(2)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by:
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Facility to ensure all medications are centrally stored and inaccessible to residents in care. Sbmit policy and procedures regarding storage of medications. POC due 3/10/23.
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LPA's observations of medication bottle on resident(R2's) night stand. The medication shoud be centrally stored as required by regulations. This is a risk health & safety and/or a personal rights risk to residents in care.
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Type B
03/17/2023
Section Cited
CCR87625(b)(3)

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Managed Incontinence (b)(3)
(b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by:

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Facility to ensure the resident room is free from urine odors, including the faciity's other areas of the home. Facility to clean the resident room and ensure continued maintenance of the room to keep the facility free of urine odor. POC due 3/17/23.
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LPA's observations, R2's room smells strongly of urine, the resident is incontinent. LPA could smell the urine odor upon entering the facility to conduct the visit. The room needs to be cleaned and free from urine odor. This is a risk to personal rights of residents in care.
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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
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2023


LIC809 (FAS) - (06/04)
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