496803915-7-20-2022-21-AS-DALO-CGHU98-20220720152243

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803915
Report Date: 07/20/2022
Date Signed: 07/20/2022 03:23:08 PM

Document Has Been Signed on 07/20/2022 03:23 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:	MARIE'S CARE HOME		FACILITY NUMBER:	496803915
ADMINISTRATOR:	BISCOCHO, LIZA		FACILITY TYPE:	740
ADDRESS:	7334 CARIOCA CT.		TELEPHONE:	(707) 794-0591
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Liza Biscocho-Administrator		TIME COMPLETED:	03:20 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) Dina Alviso conducted 1 year required inspection and met with Licensee Administrator Lza Biscocho. The inspection is focused on the Infection Control procedures and practices of this facility. There were five(5) residents in care at the facility during this inspection. There is an approved hospice waiver for three (3) residents. Facility has an approved dementia plan of operation. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden. Administrator recently submitted the facility's new Infection Control Plan as required. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly during the inspection. All smoke alarms(9) were checked during the inspection and working properly. One of the smoke alarms in the hallway is also a carbon monoxide alarm, it was working properly when checked. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. There was a sufficient supply of food.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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: MARIE'S CARE HOME	FACILITY NUMBER: 496803915
	VISIT DATE: 07/20/2022

NARRATIVE

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All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE) for staff use as required. LPA observed the Administrator and caregiver on duty, had masks on as required.

LPA observed a wheeled seating/walker blocking an emergency exit door in the resident's room. This deficiency will be cited, Fire Safety 87203-see LIC809D. It was made known to the LPA when obtaining information from the Administrator regarding a facility incident report that a staff (S1) has declined to be vaccinated and S1 doesn't have the required valid exemption. This deficiency will be cited, Health & Safety Code 1550(c) -see LIC809D.

LPA are requesting the following documents be updated and submitted to CCL by 7/27/22:

LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610 - Emergency Disaster Plan
Copy of Current Lease Agreement
Copy of Current Liability Insurance
Copy of current Administrator Certificate when received

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 the Administrator. Appeal rights provided 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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/20/2022 03:23 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: MARIE'S CARE HOME	FACILITY NUMBER: 496803915
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1550(c)

H&S Code 1550(c ) Licenses or administrator Certificates; suspension, revocation or denial of application; grounds: (c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on information the LPA obtained from the Licensee/Administrator failed to ensure the above due to S1 (staff) having declined the COVID vaccines, as required by Department PINs, and not obtaining a valid exemption as required. This is an immediate health, safety and personal rights risk to residents in care.
	POC Due Date: 07/21/2022
	Plan of Correction
1 2 3 4	Licensee, and all facillity must be in complaince with regulations, the Department's PINs, State Orders, and Public Health Orders as required. Licensee to submit a correction plan by 7/21/22. Licensee to submit proof of vaccinations or a vaild exemption with required supporting documents to CCL by 7/25/22.

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 as the LPA observed a seated/walker blocking an emergency exit door in a resident's room, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/21/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that the fire clearance of the facility is maintained at all times; Licensee removed the walker from the front of the resident emergency exit during the inspection. Administrator stated their understanding to the LPA. Administrator to submit the facility's plan in ensuring none of the exit doors, including emergency exit doors are free from obstruction at all times. POC due 7/21/22.

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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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