496803876-4-23-2024-21-AS-DALO-D4LW3D-20240423165544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803876
Report Date: 04/23/2024
Date Signed: 04/23/2024 04:55:55 PM

Document Has Been Signed on 04/23/2024 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:	CWH SANTA ROSA, INC		FACILITY NUMBER:	496803876
ADMINISTRATOR:	CLARK, CATHERINE		FACILITY TYPE:	740
ADDRESS:	100 CREEK WAY		TELEPHONE:	(707) 526-4400
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	5	CENSUS: 4	DATE:	04/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Cathy Clark-Administrator		TIME COMPLETED:	05:15 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), Alviso and Florio, conducted a Required- 1 Year visit, on 4/23/24 at approximately 11:15pm, and met with Administrator/Licensee Catherine (Cathy) Clark. Currently there are four (4) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. Facility has a required infection control plan. Facility has a required emergency disaster plan. Fire clearance is approved for five (5) non-ambulatory, which includes two (2) bedridden, effective 10/30/23. Bedridden clearance is for #3 only. LPAs reviewed resident records, four (4) of four (4). LPAs reviewed five (5) staff files. All staff have criminal record clearance as required. All staff have First Aid and CPR certification as required. All staff have required training. LPAs toured the facility with the Administrator. All exits were free and clear of obstruction. Fire extinguisher was serviced and charged, as required. Facility has smoke alarms, which are also carbon monoxide detectors, in each bedroom, hallway, and common area, except in the kitchen. Hot water was checked at 119.1 degrees Fahrenheit, which is within regulation. Facility had a sufficient supply of food. Facility had required 72 hour shelter in place food, water, and other emergency supplies on hand. Facility had sufficient supply of hygiene products, cleaners/disinfectants, and paper supplies. Facility had sufficient supply of linens, towels, and furnishings for resident use. All bathrooms had grab bars, and non-slip surface/non-skid mats for resident use. Facility had sufficient lighting in all common areas, bedrooms, bathrooms, and hallways Continued on LIC809C....

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CWH SANTA ROSA, INC	FACILITY NUMBER: 496803876
	VISIT DATE: 04/23/2024

NARRATIVE

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.The backyard has outdoor furnishings for resident use, and a shaded area for residents use. The outside walkways were clear and unobstructed. Medications were locked and inaccessible to residents in care. Cleaners/disinfectants were locked and inaccessible to residents in care.

LPA is requesting the following documents be updated and submitted by 5/23/24:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
LIC400 Handling of Client Cash Resources -(complete even if not handling cash)
Surety Bond copy (if handling cash)
Liability Insurance-Current copy
Resident Roster

The following deficiencies were observed during the investigation, and will be cited:

Per LPAs file reviews, R1's medications are being brought into the facility daily, and administered by responsible party(s,) morning and night. LPA discussed medication regulations with the Administrator. Incidental Medical and Dental Care 87465(a)(4)- A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed, see LIC809D.

Per LPAs file reviews, LPAs observed medication records were not accurate, updated and/or missing. Incidental Medical and Dental Care 87465 (h)(6)(A-F) The following requirements shall apply to medications which are centrally stored:The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year, see LIC809D.

Continued on LIC9809C....

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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: CWH SANTA ROSA, INC	FACILITY NUMBER: 496803876
	VISIT DATE: 04/23/2024

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Per LPAs file reviews, four out of four residents lack pre-appraisal/appraisals and/or needs and service plans. Reappraisals 87463(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition, see LIC809D.

Deficiencies 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 Licensee/Administrator.
Appeal Rights provided to the Licensee/Administrator. l

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/23/2024 04:55 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: CWH SANTA ROSA, INC	FACILITY NUMBER: 496803876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on four (4) out of four (4) resident record reviews, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure that all residents have appraisals/reappraisals and/or care plan in place ensuring all residents needs are being met by facility. Submit future plan of facility compliance and copy of the four resident care plans/appraisals. POC due by 5/3/24.

Type B

Section Cited

CCR

87465(h)(6)(A-F)

Incidental Medical and Dental Care (h)(6)(A-F) The following requirements shall apply to medications which are centrally stored:The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: The name of the resident for whom prescribed. The name of the prescribing physician. The drug name, strength and quantity. The date filled. The prescription number and the name of the issuing pharmacy. Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on four (4) out of four (4) resident medication record reviews, the licensee did not comply with the section cited above. LPAs observed records were not accurate, updated and/or had missing information. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	LIcensee/administrator to ensure all medication records are accurate and complete with all medications logged for each resident; Licensee/administrator to submit written self-certification that medication records are in compliance; LIcensee/administrator to submit a plan of correction stating how the facility will stay in compliance with this regulation moving forward. POC due by 5/10/2024.

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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/23/2024 04:55 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: CWH SANTA ROSA, INC	FACILITY NUMBER: 496803876
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on , record reviews and interviews, R1's medications are being handled by resident's responsible party (RPs)(s) day and night, RPs bring the medication into the facility daily and administer it to the resident, the licensee did not comply with the section cited above in one (1) out of four (4) resident needing assistance with medications, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to ensure the facility is in compliance with regulation regarding the medication assistance for resident R1. Submit plan of correction of the facility assisting R1 with their medications as required by regulation, and future plan of facility compliance with this regulation. POC due 4/24/24.

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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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