496803905-5-1-2023-21-AS-DALO-CRF36F-20230501175814

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803905
Report Date: 05/01/2023
Date Signed: 05/01/2023 05:58:26 PM

Document Has Been Signed on 05/01/2023 05:58 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:	ARBOL RESIDENCES OF SANTA ROSA		FACILITY NUMBER:	496803905
ADMINISTRATOR:	SORIANO, MARIELE		FACILITY TYPE:	741
ADDRESS:	300 FOUNTAINGROVE PARKWAY		TELEPHONE:	(707) 566-8600
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	152	CENSUS: 103	DATE:	05/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Mariele Soriano-Administrator		TIME COMPLETED:	06:00 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 Analyst (LPA), Alviso, conducted a Required 1-Year visit, on 5/1/23 at approximately 10:00am, and met with Administrator/Executive Director Mariele Soriano. The facility is a licensed continuing care retirement community, consisting of an assisted living building, which includes dementia care services unit, and a skilled nursing building. The LPA is reporting on the assisted living, and dementia unit, in today's visit. The skilled nursing building is monitored by Department of Health. There is a total capacity of one hundred and three(103) residents in the assisted living and dementia unit. There are thirty-three(33) patients in the skilled nursing building. Facility has a dementia plan of operation approved by the Department. Hospice waiver approved for 15 residents. The facility has submitted the required infection control plan, which is part of the facility's plan of operation. Facility has the required facility emergency and disaster plan, including emergency drills, and evacuation drills. Fire clearance approval for 152 non-ambulatory, which includes 25 bedridden; Third(3rd) floor is approved for non-ambulatory only. LPA toured the facility with the Administrator Mariele; The Administrator had Health Services Director Rogina McBurny, and Plan of Operations Director Paul Crum, join the tour. LPA observed comfortable furnishings throughout the facility. The grounds were free of any observed hazards, and all exits were free of obstructions. Fire extinguishers were serviced and tagged as required-expires 10/10/2023. Facility is sprinkled, and has a hard wired smoke alarm system in place. The smoke alarms system also checks is a carbon monoxide detector. No bodies of water/water features on grounds. 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: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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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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: ARBOL RESIDENCES OF SANTA ROSA	FACILITY NUMBER: 496803905
	VISIT DATE: 05/01/2023

NARRATIVE

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LPA observed medication room for assisted living area, and a medication room in the memory care unit; Medications will be locked and inaccessible to residents in care. LPA observed first aid kits with supplies required, and first aid booklet.

The hot water was checked at 118.4F and 115.F which is within regulation. Hot water is supplied by two(2) boiler tanks. Facility has an elevator for resident, staff, and visitor use; The elevator was inspected on 3/15/23, permit renewed and expires 3/15/2024.

Facility has a sufficient perishable, and non-perishable food supply. Food is ordered three times a week, and more often if needed. Facility had emergency supplies to meet requirement for the 72 hour shelter in place; Administrator provided a copy of additional emergency food supplies ordered from Meals for all Company. These planned meals have a longer shelf life, and were ordered for the continuing care community's emergency 72 hour shelter in place food supplies.

Facility has emergency supplies, including flashlights, first aid supplies, and other items as listed in the emergency plan/disaster plan. LPA observed three evacuation chairs at the top of all three(3) 3rd floor stairwells.

There is a permanently placed large generator that in an emergency can run half (1/2 ) the lights in the hallways of the AL, the memory care unit, and in the skilled nursing building, as well as other items. Facility has a sufficient supply Personal Protective Equipment (PPE) for use as needed. Facility has a sufficient supply of hygiene products, cleaners, and paper products for use as needed. The facility bathrooms have grab bars and non-slip mats/non-slip type flooring for resident use when bathing/showering. Sufficient lighting was observed by the LPA in hallways, common areas, and resident units seen by the LPA.

The facility has conducted a full emergency evacuation drill on 2/9/2023; Evacuation drills are done twice a year. Emergency fire drills are completed every month, these when done will be on different shifts, last drill completed on 4/19/23.

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: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2023 05:58 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: ARBOL RESIDENCES OF SANTA ROSA	FACILITY NUMBER: 496803905
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care Of Persons With Dementia(f)(2) The following shall be stored inaccessible to residents with dementia: 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 LPA's observation, the licensee did not comply with the section cited above in [2] out of [3] housekeeping carts that were checked and found to have all cleaners/disinfectants accessible to residents in the memory care and in assisted living. One houskeeping cart had no lock on it and was tied with a plastic bag and the other housekeeping cart in memory care was unlocked and turned to the wall with all toxins left accessible to residents which poses an immediate health, safety risk to persons in care.
	POC Due Date: 05/02/2023
	Plan of Correction
1 2 3 4	Facility to ensure all housekeeping carts are working as they are meant to be, properly; Ensure all toxins/cleaners are inaccessible to residents in care per regulations. Submit plan on how the facility corrected the deficiency regarding the locking up of the toxins/cleaners on the hosekeeping carts of the facility. Submit plan on compliance with this regulation and in-service with all staff regarding storage of cleaners/toxins and keeping them inaccessible at all times. Proof of training due 5/12/2023. POC due 5/2/23.

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: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

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: ARBOL RESIDENCES OF SANTA ROSA	FACILITY NUMBER: 496803905
	VISIT DATE: 05/01/2023

NARRATIVE

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This Required 1-Year will be continued by the LPA at a later date.

LPA observed that there were two(2) housekeeping carts with oxins/cleaners left accessible to residents in care; , One(1) didn't have a lock on it and was tied by a loose plastic bag, and the other one(1) was left unlocked by the housekeeper and faced against the wall. This is a deficiency and will be cited per regulations, Care Of Persons With Dementia(f(2) , The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants, 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.
Appeal rights given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023

LIC809 (FAS) - (06/04)

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