<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:40:20 PM


Document Has Been Signed on 09/10/2024 04:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SONOMA GROVEFACILITY NUMBER:
496803924
ADMINISTRATOR:ALEXANDER VARSHAVSKYFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(415) 264-5486
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY:32CENSUS: 26DATE:
09/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Alex Varshavsky, AdministratorTIME COMPLETED:
04:55 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) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by corporate board member, Julia Latifi. Administrator Alex Varshavsky arrived later.

At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and common areas of facility have portable air conditioner and four overhead air conditioner. However, rooms do not have portable air conditioners. Rooms have small fans. LPA discussed with Admin adding a small portable air conditioner for each room, especially during the summer months when temperatures reach over 100 degrees F, as it is probable that fans do not cool rooms under 85 degrees F. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food items were not found to be stored in a safe manner with open items that were not covered and sealed; open loaf of bread with bread pieces spilled on the floor, open and uncovered box of croissants, flour in a metal container covered in plastic wrap labeled 12/12/23, sour cream tub and cream cheese tub opened but not labeled with date (deficiency cited, see 809D).

All bedrooms were equipped with night stand, and chest of drawers. Six [6] our of sixteen [16] rooms had lamps present but were not working. Room #2 has a broken bathroom window, LPA found a wooden spoon lodged between window and window sill to keep the window open. Room #8 has a broken window, the inner frame of the window is broken and separated from the glass. Room #10 has a hole in the wall opposite of the beds. (deficiency cited, see 809D). Extra hygiene products and linens were available. Resident bathrooms all had grab bars and anti-slip strips present. The main bathroom did not have required bath mat and community/unassigned towels present. Water temperature in sink accessible to residents in care in main bathroom measured at 105.2 degrees F which is within the allowable range of 105 to 120 degrees F.

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 17


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SONOMA GROVE
FACILITY NUMBER: 496803924
VISIT DATE: 09/10/2024
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
26
27
28
29
30
31
32
Continued from 809...

However, water temperature in sink accessible to resident in room #7 measured at 99 degrees F, in room #8 measured at 84 degrees F, in room #11 at 96 degrees F, in room #12 measured at 97 degrees F, and in room #16 measured at 87 degrees F which are all outside of the allowable range of 105 to 120 degrees F (deficiency cited, see 809D). LPA observed urine on toilet chair in room #2 along with spots of a dried brownish reddish substance. Curtains in room #14 had brown substance in various spots (deficiency cited, see 809D).

Fire extinguishers were last inspected 10/23/2023. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced quarterly by Nemesis Fire, last serviced on 8/21/2024. Facility’s last quarterly disaster drills were conducted 9/2/2024. Facility has a backup generator for use during a power outage.

At approximately 11:30am LPA conducted review of 6 staff records. Five [5] out of six [6] staff did not have at least 20 hours of annual training completed. (deficiency cited, see 809D). LPA and Admin discussed training materials and the possibility of utilizing an approved vendor for training to complete staff training requirements. Facility will submit current training materials to CCL for approval.



At approximately 1:30pm LPA and Med Tech conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA discussed with Med Tech adding date started to bottles and list on Centrally Stored Medication Log as best practices.

At approximately 2:30pm LPA conducted a review of 6 resident records. R5 most current appraisal dated 2/1/2023 (deficiency cited, see 809D). Residents R1, R2, R3, and R4 all have bedridden status but facility has fire clearance for two bedridden residents. LPA and Admin discussed either notifying the local fire department of additional bedridden residents via fax or submit to licensing an updated LIC200 along with an updated facility sketch and CCL will request an inspection to update fire clearance for bedridden allowance. Admin chose to submit an updated LIC200 and facility sketch. Once received CCL will submit to local fire department.

Continued on 809C(2)...

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 17
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SONOMA GROVE
FACILITY NUMBER: 496803924
VISIT DATE: 09/10/2024
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
26
27
28
29
30
31
32
Continued from 809C...

Alex Varshavsky Administrator Certificate 7019479740 expires 7/15/2026. All fees are current as of this time.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 4 of 17
Document Has Been Signed on 09/10/2024 04:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SONOMA GROVE
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(A)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary.  These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. 

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed urine on toilet chair in room #2 along with spots of a dried brownish reddish substance. Curtains in room #14 had brown substance in various spots, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Facility to clean or replace curtains in room #14 and self-certify on LIC9098 that all toilets and toilet seat chairs in facility will be cleaned and in compliance with regulation 87470(a)(2)(A). Photos of replaced or cleaned curtains to be submitted along with LIC9098 by plan of correction due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that room #2 has a broken bathroom window, LPA found a wooden spoon lodged between window and window sill to keep the window open. Room #8 has a broken window, the inner frame of the window is broken and separated from the glass. Room #10 has a hole in the wall opposite of the beds, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Facility to repair broken windows in rooms #2 and #8 and repair hole in wall in room #10 by plan of correction due date. Facility to submit photographic proof of repairs by plan of correction due date.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 5 of 17


Document Has Been Signed on 09/10/2024 04:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SONOMA GROVE
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3, S4, and S5 did not have the required hours of annual training completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
1
2
3
4
Facility to submit training materials to CCL for approval by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 10/1/2024. Training log to include name of trainer, name of course, staff attendees, date of completion including the year, and hours completed. If an approved vendor is chosen facility to submit certificates of completion in lieu of training log.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that food items were not found to be stored in a safe manner with open items not covered and sealed; open loaf of bread with bread pieces spilled on the floor, open and uncovered box of croissants, flour in a metal container covered in plastic wrap labeled 12/12/23, sour cream tub and cream cheese tub opened but not labeled with date, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Facility to conduct staff training on how to properly store opened food items. Facility to submit trainng log and materials used to administer training by POC due date. Training log to include name of trainer, name of course, staff attendees, date of completion including the year, and hours completed. If an approved vendor is chosen facility to submit certificates of completion in lieu of training log.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 6 of 17


Document Has Been Signed on 09/10/2024 04:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SONOMA GROVE
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R5's most current appraisal is dated 2/1/2023, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/17/2024
Plan of Correction
1
2
3
4
Facility to conduct a current appraisal of R5 and submit LIC603 for R5 to CCL by plan of correction due date. LIC603 to be executed by resident or resident responsible party and Admin by plan of correction due date.

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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 7 of 17


Document Has Been Signed on 09/10/2024 04:40 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: SONOMA GROVE
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation, the licensee did not comply with the section cited above in that water temperature in sink accessible to resident in room #7 measured at 99 degrees F, in room #8 measured at 84 degrees F, in room #11 at 96 degrees F, in room #12 measured at 97 degrees F, and in room #16 measured at 87 degrees F which are all outside of the allowable range of 105 to 120 degrees F, which poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 09/24/2024
Plan of Correction
1
2
3
4
Facility to submit water temperature log with 2 weeks of water temperature readings that are within regulation. Pictures of water temperature to be shown with thermometer and thermometer reading present in picture, and be taken in rooms identified in the deficient practice statement. Log and pictures to be submitted by plan of correction due date.
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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
Page: 17 of 17