496803936-10-20-2022-21-AS-DALO-CKDT5W-20221020142614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803936
Report Date: 10/20/2022
Date Signed: 10/20/2022 02:26:24 PM

Document Has Been Signed on 10/20/2022 02:26 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:	NAPA-SONOMA QUALITY CARE HOME LLC		FACILITY NUMBER:	496803936
ADMINISTRATOR:	TAPNIO, RYANNE		FACILITY TYPE:	740
ADDRESS:	4990 FILAMENT CIRCLE		TELEPHONE:	7075953766
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	6	CENSUS: 3	DATE:	10/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Joyce Torres-Lead Caregiver		TIME COMPLETED:	02:35 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, conduct a Required- 1 Year inspection and met with Lead staff Joyce; LPA observed another caregiver working, Grazelle.. The inspection is focused on the Infection Control procedures and practices of the facility. The LPA was screened as required by staff, including LPA's temperature, all information was logged as required. Administrator has submitted the Infection Control Plan as required. There is an approved hospice waiver for two (2) residents. There is an approved plan of dementia care. Fire clearance is approved for six (6) non-ambulatory. Per Administrator, fire extinguishers, two(2) of them, were purchased within the last few months from Costco; The Administrator will attach copy of receipt to extinguishers and ensure they are both serviced and tagged as required.-annually. There were three(3) residents in care at the facility during the inspection. LPA observed the facility to be clean and orderly. The facility was at a comfortable temperature for the residents in care. There was a sufficient supply of food for residents in care. All exits were unobstructed. There was a sufficient supply of hygiene products, paper products, and cleaners. Sufficient supply of PPE. Medications are locked and inaccessible to residents in care. Toxins and cleaners are locked and inaccessible to residents in care. LPA observed the following deficiencies: LPA observed that the garage has been renovated/conversion to have staff room and 2nd bed set-up and used by staff. 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: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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: NAPA-SONOMA QUALITY CARE HOME LLC	FACILITY NUMBER: 496803936
	VISIT DATE: 10/20/2022

NARRATIVE

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The garage conversion was completed without permits and Licensee had not notified the licensing agency of any changes to the facility grounds. This can jeopardize the facility's fire clearance. LPA contacted the Rohnert Park Fire Inspector who arrived to inspect the garage conversion. The Fire Inspector Jim Thompson left an inspection record to the Licensee for follow-up on the conversion that was not permitted. Deficiency will be cited, Fire Safety 87203-see LIC809D.

LPA observed staff (S1) to greet the LPA in the facility front entryway without a mask on. This will be cited, Personal Rights 87468.1(a)(2)- see LIC809D.

LPA observed staff change a resident, provide incontinent care services, in the open sitting area of the facility, this is by the front door entry. The resident was not given personal privacy when being provided personal care needs. This will be cited, Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(1)-see LIC809D.

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

Licensee/Administrator to submit the following documents by 10/31/22:

LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 9020 Register of Residents
LIC 610 E Emergency Disaster Plan for Residential Care Facilities for the Elderly
Copy of Liability Insurance

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2022 02:26 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: NAPA-SONOMA QUALITY CARE HOME LLC	FACILITY NUMBER: 496803936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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) (interview) (record review)], the licensee did not comply with the section cited above-the garage has been renovated, a room was added and other renovations throughout the garage area, all work was done withoout required permits which poses an immediate health, safety risk to persons in care. Immediate Civil Penalty fine is assessed today in the amount of $500. LPA contacted the Fire Inspector Jim Thompson who came out to the facility and inspected the garage. LPA obtained a copy of Field Inspection Record from the Fire Inspector.
	POC Due Date: 10/21/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that they contact the Planning Department for a permit(s) and contact the Rohnert Park Fire Department, Fire Inspector Jim Thompson, regarding the converted garage to try and obtain approval on the renovations. Submit copy of obtained permit(s), approval and/or orders from Planning Department/Fire Department when received. Licensee to submit plan of correcting this fire safety violation, and continue to keep Licensing Agency updated on the garage conversion status. POC due 10/21/22.

Type A

Section Cited

CCR

87468.1(a)(2)

Personal Rights 87468.1(a)(2)- Residents in assisted living-ensuring personal rights are not violated at any time. This requirement is not met as evidenced by: Staff observed to come to the front door entry to greet the LPA without a mask on. LPA discussed that all staff are required to wear a mask at all times.
	Deficient Practice Statement
1 2 3 4	Based on LPA's [(observation), the licensee did not comply with the section cited above in [1] out of [2] staff persons, which poses an immediate health, safety and/or personal rights risk to persons in care.
	POC Due Date: 10/21/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that staff are wearing appropriate PPE at all times as required. Licensee to hold an inservice with all staff the requirement of wearing an appropriate mask when working at the facility-at all times. Submit proof of inservice with all staff regarding mask requirement, and submit copy of attendees, date & time spent, by 10/24/22. Plan of correction due 10/21/22.

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: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2022 02:26 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: NAPA-SONOMA QUALITY CARE HOME LLC	FACILITY NUMBER: 496803936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.2(a)(1)

87468.2(a)(1) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by: LPA observed the two staff on duty, S1 & S2, change a resident in the open sitting area by the front door entry of the facility; The resident was exposed to everyone who may walk into the room, staff, visitors, other residents.There was no personal privacy given to the resident when providing incontinent care services.
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in [1] out of [3] residents which poses an immediate personal rights risk to persons in care.
	POC Due Date: 10/21/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff are in-serviced regarding all "residents rights" in regulations and ensure all residents are given personal privacy when providing personal service/care needs to to residents. Submit copy of training date & time spent, and all attendees by 10/25/22. Plan of correction due 10/21/22.

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: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

LIC809 (FAS) - (06/04)

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