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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803941
Report Date: 06/11/2024
Date Signed: 06/11/2024 03:39:59 PM

Document Has Been Signed on 06/11/2024 03:39 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:ASHKALON HOUSEFACILITY NUMBER:
496803941
ADMINISTRATOR/
DIRECTOR:		DADA, VICTOR C.FACILITY TYPE:
740
ADDRESS:912 DETURK AVE.TELEPHONE:
(707) 478-7411
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 2DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator/Licensee, Victor DadaTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Licensee/Administrator, Victor Dada. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 6 non-ambulatory residents. Facility has an approved hospice waiver for 2 individuals. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were 2 Residents in care and 3 staff members on-site.

At approximately 9:55AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 10:00AM, LPA conducted a walk-though of the facility with Licensee. LPA observed the following: Facility is a one story building with six bedrooms, six bathrooms, and common spaces. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for all sinks were found to be within Title 22 Regulations of 105 to 120 degrees Fahrenheit. LPA observed that one facility's fire extinguisher shows that it was last inspected April 2023, while the other fire extinguisher was shown to be last inspected April 2025 (see LIC9102, Regulation 87202(a)). Per interview with Licensee, they have not done an emergency/disaster drill recently (see LIC809D, Health and Safety Code, 1569.695(c)). Licensee understands that emergency/disaster drills are to be conducted at least quarterly per Health and Safety Code. During walkthrough, LPA observed the following toxins to be accessible: Snuggle scented dissolvable beads, Tide Detergent Pods, floor cleaner, and flea/tick repellent (see LIC809D, Regulation 87705(f)(2)). Licensee immediately collected all toxins and ensured that they were locked. Smoke and carbon monoxide detectors were tested and operational.

At approximately 11:00AM, LPA reviewed staff files, resident files, and resident medications.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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 8
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: ASHKALON HOUSE
FACILITY NUMBER: 496803941
VISIT DATE: 06/11/2024
NARRATIVE
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Continued from LIC809

Review of staff files showed that 1 of 3 staff members were missing their Health Screening (LIC503) report. 2 of 3 staff members did not have annual 2024 training completed (see LIC9102, Regulation 87411(f), and LIC809D, Health and Safety Code, 1569.625(b)(2)). Staff files had current First Aid and CPR certification, and proof of negative TB tests. Review of Resident Files showed that 2 of 2 files were missing their Pre-Appraisal Assessments (LIC603) (see LIC809D, Regulation 87506(b)(15)). Licensee understands that Pre-Appraisal assessments should be conducted prior to residents moving into the facility. Licensee also understands that assessments and appraisals should be conducted annually for residents with a dementia diagnosis. LPA observed that 2 of 2 resident files did not have a Needs and Services Plan (see LIC9102, Regulation 87467(a)). Review also showed that 1 of 2 resident files were missing hospice documentation (see LIC9102, Regulation 87633(b)). Per interview with Licensee, resident just moved in, and they are still waiting for hospice documentation to arrive.

Administrator's Certificate for Victor Dada (6000794740) expired 03/31/2024. Review of the Department website showed that renewal payment has been received and is pending as of 01/11/2024.

LPA requested the following documentation to update the facility file:

  • Designation of Facility Responsibility (LIC 308)
  • Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Register of Clients/Residents (LIC 9020)
  • Updated Lease
  • Updated Liability Insurance
  • Active and Current Administrator Certificate
Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 07/11/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 06/11/2024 03:39 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 06/11/2024 at 02:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ASHKALON HOUSE
FACILITY NUMBER: 496803941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview conducted and records reviewed, the Licensee did not comply with the section cited above. Facility has not conducted an emergency/disaster drill as required by Health and Safety Code. This poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 06/12/2024
Plan of Correction
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Licensee to submit a written plan to CCL outlining how they will ensure that disaster drills are conducted quarterly as required by POC due date of 06/12/2024. Licensee to submit proof that an emergency drill has been conducted with facility staff and residents and submit to CCL by POC due date of 06/22/2024.
Type A
Section Cited
CCR
87705(f)(2)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, the Licensee did not comply with the section cited above. LPA observed toxins such as snuggle dissolvable beads, tide detergent pods, wood floor cleaner, and flea/tick repellent. This poses an immediate health, safety or personal rights risk to residents in care. LPA observed that Licensee immediately put toxins in a locked closet.
POC Due Date: 06/12/2024
Plan of Correction
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Licensee to submit a self-certification stating that an in-service training will be conducted for all staff by POC due date of 06/12/2024. Licensee to submit completed training to CCL by POC due date of 06/22/2024.
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 Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 06/11/2024 03:39 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 06/11/2024 at 02:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ASHKALON HOUSE
FACILITY NUMBER: 496803941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review, the Licensee did not comply with the section cited above. Licensee did not ensure that facility staff had annual staff training completed as required. This poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 06/22/2024
Plan of Correction
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Licensee to submit a written plan to CCL on how they will ensure training will be completed timely each year. Licensee to submit proof of completed training for 2 of 2 facility staff by POC due date of 06/22/2024.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Licensee did not comply with the section cited above. Licensee did not complete a Pre-Appraisal as required for 2 of 2 residents. This poses/posed a potential health, safety or personal rights risk to residents in care.
POC Due Date: 06/22/2024
Plan of Correction
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Licensee to complete the pre-appraisal assessments for 2 of 2 residents and submit proof to CCL by POC due date of 06/22/2024.
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 Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024


LIC809 (FAS) - (06/04)
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