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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 08/09/2022
Date Signed: 08/11/2022 09:50:35 AM


Document Has Been Signed on 08/11/2022 09:50 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/10/2022 12:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

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*****AMENDED*****Licensing Program Analyst (LPA), Shannan Hansen arrived unannounced to conduct a required 1-year Infection control inspection at approximately 8:50 AM, and met with Licensee Julia Latifi. The inspection is focused on the Infection Control procedures and practices of this facility. There are currently 21 residents in care, 13 dementia and 1 on hospice.

Upon entry LPA was screened for COVID symptoms and asked to sign in. At primary entrance LPA was temperature checked and provided hand sanitizer and visitor sign in sheet. LPA conducted walk through of the facility with Licensee and observed COVID postings throughout.

LPA toured the building and grounds which were found to be clean and in good repair. Facility was a comfortable temperature and all walkways and exits were observed to be unobstructed. The amount of fresh and nonperishable foods is within regulation. Toxins are stored and inaccessible to residents in care. Water temperature measured at 110.3 and 105 degrees F which is within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguisher inspected was charged dated 9/16/2021. LPA was provided with invoice from third party company responsible for inspecting fire safety system which includes smoke detectors and sprinkler system dated March 17, 2022. There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All bedrooms have lighting & appropriate furnishings.

Hand sanitizer is kept throughout the facility. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. Toxins are secured and inaccessible in locked housekeeping closets. A 30 day supply of medications are centrally stored and secured.

Continued on LIC 809C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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Document Has Been Signed on 08/11/2022 09:52 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/10/2022 12:53 PM

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: SONOMAMODELX
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with Licensee & record review, the licensee did not comply with the section cited above in 3 out of 8 staff working were did not have the proper fingerprint clearance and were not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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Licensee agrees to send in written plan of correction that they understand all staff must be fingerprint cleared and associated prior to working in the facility. POC due date of 8/10/2022.
****Amended Civil Penalties issued in the amount of $300.00.****
Type A
Section Cited
CCR
87355(e)(2)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview with Licensee and record review, the licensee did not comply with the section cited above in 1 out of 5 staff weren’t associated to facility which poses a potential health, safety or personal rights risk to persons in care. During visit on 8/9/2022 LPA observed staff S1 was working w/residents and not associated to facility this day.
POC Due Date: 08/10/2022
Plan of Correction
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LIcensee agrees to associated S1 by POC date 08/10/2022. Licensee agrees to ensure any staff working or residing in the facility are fingerprint cleared and associated.
****Amended Civil Penalties in the amount of $100.00.*****

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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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: SONOMAMODELX
FACILITY NUMBER: 496803924
VISIT DATE: 08/09/2022
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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. LPA and staff discussed resident activities which include bingo and music. Visits are occurring both indoors and outdoors. Residents do not frequently leave the facility but there are procedures in place to screen residents when returning from outings.

Infection Controle:

Facility has submitted a mitigation program plan that was approved, and Infection Control Plan has been requested again on 8-3-22 via email from LPA. All staff, clients, & visitors check in with the electronic temperature and log, and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in hallway closet and in garage. Staff had all PPE training required on file as well have been N95 Fit Tested.



LPA reviewed Licensing Information System (LIS) with Assistant Administrator who stated that is correct other then Administrator no longer works at facility and a new one will be replacing in a couple of weeks, at this time; no need to change any of the information. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted every 3 months with the last one being conducted on 6/7/2022.

LPA obtained list of staff working at time of visit and checked with current Guardian list which showed: S1 was background cleared and associated to another facility but not associated to this facility. S2, S3, and S4 do not have DOJ background clearance as required by Regulations. LPA discussed with Licensee who agreed to call other staff to cover for unfingerprinted staff. LPA informed Licensee to contact Guardian at 888-422-5669 for clearance of staff and to transfer cleared record, Licensee may call CCL and submit a copy of staff’s current CA or US ID, LIC 508, & LIC 9182.
*****AMENDED on 8/11/2022 to issue Civil Penalties for 3 staff not fingerprint cleared and 1 staff not associated. Civil Penalties issued in the amount of $400.00.

Facility is being cited today for 87355(e)(1) Criminal Record Clearance & 87355(e)(2) transfer of criminal record clearance or association to facility.

LPA was presented with proof of CPR & 1st Aid certification for staff which files were reviewed.
Administrator Certificate is for Alexander Varshavsky #6052513740 Exp. 7/15/2023
All staff and residents have received COVID booster vaccinations and inclusively work at this facility.
Continue on LIC809-C2
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 8
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: SONOMAMODELX
FACILITY NUMBER: 496803924
VISIT DATE: 08/09/2022
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LIC 809C-2
LPA was presented with proof of CPR & 1st Aid certification for staff which files were reviewed.
Administrator Certificate is for Alexander Varshavsky #6052513740 Exp. 7/15/2023
All staff and residents have received COVID booster vaccinations and inclusively work at this facility.

Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and 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 and appeal of rights provided..



LPA Hansen is requesting Licensee to update and submit the following documents by 8/31/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8