496803924-9-17-2020-21-AS-KMOA-BTJTSL-20200917145920

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 09/17/2020
Date Signed: 09/17/2020 02:59:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	SONOMA GROVE		FACILITY NUMBER:	496803924
ADMINISTRATOR:	VARSHAVSKY, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	765 DONALD STREET		TELEPHONE:	(415) 264-5486
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	32	CENSUS: 6	DATE:	09/17/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Alex Varshavsky & Julia Latifi		TIME COMPLETED:	03:10 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) Mota conducted a pre-licensing inspection and was greeted by Jennie Bagley, Caregiver. Applicant, Julia Latifi was contacted and arrived at the facility shortly after. This pre-licensing inspection is being conducted due to a change of ownership. Due to COVID precautions, LPA donned full PPE consisting of a gown, gloves, N95 mask and face shield. LPA will conduct Component III Orientation during today's inspection. Fire Clearance has been approved for 30 non-ambulatory and 2 bedridden residents. The facility has been approved for a hospice waiver for 10. There are currently 6 residents in care, some of which are diagnosed with Dementia. No residents are on hospice. LPA observed no visitors signs at the front entrance. A screening area is inside the front door which includes, temperature taking, hand sanitizer and sign in log. LPA toured both the interior and exterior portions of the facility. Exit doors are alarmed and functional. Fire extinguishers were charged 8/12/2020. Smoke detectors were functional and carbon monoxide detector was present and functional. Exits were observed to be unobstructed. Hot water measured between 105.8 degrees in faucets used by residents which falls within regulation of 105 & 120 degrees F. Shower grab bars were missing in room 15 and toilet grab bar was missing in room 14. There was an ample supply of linens. There was a sufficient supply of hygiene products available for current residents. LPA observed adequate food supply per current census. Facility was found to be a comfortable temperature. Toxins were observed in the kitchen which is kept locked and in a locked storage room. All knives and other sharp items were secured in the kitchen. Required postings such as Complaint poster, Rights to resident councils, client's rights currently are not posted in the facility due to remodeling. LPA observed a courtyard area off the main room of the facility. Continued on 809-C

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Kimberley Mota	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SONOMA GROVE	FACILITY NUMBER: 496803924
	VISIT DATE: 09/17/2020

NARRATIVE

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Medications are centrally stored in a locked cart at the front desk and will eventually be stored in a dedicated locked room off the hallway.

Disaster Drills are conducted through an outside agency quarterly and fire drills are monthly. Facility does have a generator on site for the use during a power outage. LPA requested that applicants maintain a log with bi-monthly dates that generator is tested.

LPA and Applicant discussed facility's emergency disaster plan and new Assembly Bill (AB) 3098 Residential care facilities for the elderly: emergency and disaster plans. LPA provided applicant with a copy of the regulation.

Due to the facility undergoing remodeling, required postings were removed. Facility is in the process of updating the posters and will be posting once printed. LPA did observe the LTCO poster near the front door.

LPA and Applicants discussed COVID processes for mitigating and containment if necessary. LPA requested facility place additional COVID posters at the entrance and in each resident and common area bathrooms regarding hand washing.

Facility has designated Maria Flores as the Administrator, however certificate number 6048048740 expired 9/1/2020 and is in the process of being renewed.

Component III Orientation completed with Applicant during today's inspection.

Pre-Licensing is complete and this facility has no deficiencies

A copy of this report will be forwarded to the Central Applications Bureau.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5079
LICENSING EVALUATOR NAME: Kimberley Mota	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC809 (FAS) - (06/04)

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