496803960-4-3-2023-21-AS-FSAI-CQJUUC-20230403155320

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803960
Report Date: 04/03/2023
Date Signed: 04/03/2023 03:53:38 PM

Document Has Been Signed on 04/03/2023 03:53 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:	ELSA'S HOME		FACILITY NUMBER:	496803960
ADMINISTRATOR:	HUMPHREY, NICHOLAS		FACILITY TYPE:	740
ADDRESS:	10 CREEKVIEW COURT		TELEPHONE:	(707) 539-5625
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY: 6		CENSUS: 5	DATE:	04/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Caregiver, Marcia Avila		TIME COMPLETED:	04:15 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), Farhaan Sarangi arrived unannounced at Elsa's Home for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by, Caregiver Marcia Avila and was granted access into the facility. Currently, the facility is Fire Clearance approved to care for 5 Non-Ambulatory residents. However, during the review of an LIC 602, LPA observed that 1 out of 5 resident files had a status of Bedridden (See 9102-Technical Violation). Administrator and Licensee were contacted via telephone and both understood that the facility needs to seek a Bedridden Fire Clearance first before admitting a resident into the facility. LPA explained the process of seeking a Bedridden Fire Clearance for the purpose of updating the facility license. LPA toured the facility with the Caregiver. LPA observed the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on February 1, 2023 at the time of the inspection. All smoke detectors and carbon monoxide detectors sound directly to the fire station. Water temperature in residents bathroom measured at 148.6 degrees, 146.4 and 142.1 which is not an acceptable range of 105 to 120 degrees F (See 9102-Technical Violation). There was sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. (Report continued on LIC 809C)

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

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: ELSA'S HOME	FACILITY NUMBER: 496803960
	VISIT DATE: 04/03/2023

NARRATIVE

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Resident files were reviewed and residents were interviewed during the Required 1 year inspection. 4 out of 5 resident files did not have reappraisals (See LIC 809D) located inside the resident files.1 out of 5 resident files did not have an Admission Agreement (See LIC 809D). Caregiver, Marcia Avila, attempted to locate the Admission agreement and was unsuccessful. Both the Caregiver and the LPA were unsuccessful in finding this Admission Agreement. 5 out of 5 resident files did not have a Medication Assessment Record (MAR) located in the file and/or the MAR for the month of March (See LIC 809D). Caregiver, Marcia Avila, attempted to locate the MAR's for the resident files and was unsuccessful. Staff files were reviewed. Staff at the facility on this date and time were interviewed. Emergency Disaster plan was reviewed with facility staff. LPA found that the facility does not have numbers listed for Transportation Resources (See LIC 9102). Infection Control plan was reviewed with staff. LPA found that page 4 (Infection Preventionist) was not filled out and relocation sites had no addresses on them (See LIC 9102's).

LPA requested the following documents to be sent:
LIC 500- Personnel Report
LIC 308- Designation of Responsibility
LIC 309- Administrative Organization
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Updated Emergency Disaster Plan (LIC 610E)
Surety Bond
Most up-to-date Liability insurance
Control of Property
Register of residents
Fire Alarm System test
LIC 200, facility sketch and most-up-to-date Emergency Disaster Plan to reflect Bedridden resident(s)

The following deficiencies were observed (See LIC 809D's) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Caregiver. Also participating in the exit interview was the Licensee and Administrator over the phone. A copy of this report along with appeal rights were given to Facility Caregiver.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/03/2023 03:53 PM - It Cannot Be Edited

Created By: Farhaan Sarangi On 04/03/2023 at 03:01 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: ELSA'S HOME	FACILITY NUMBER: 496803960
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) 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, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 out of 5 files did not have reappraisals conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2023
	Plan of Correction
1 2 3 4	Plan of Correction (POC) shall include that ALL residents have Reappraisals performed in accordance with regulation. Furthermore, Licensee shall conduct staff training on reappraisals and a plan for future compliance.

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review,, the licensee did not comply with the section cited above in 1 out of 5 resident files did not have an Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2023
	Plan of Correction
1 2 3 4	Plan of Correction (POC) shall include ensuring that ALL Admission Agreements are retained in the resident files. Furthermore, Licensee shall conduct staff training on Admission Agreements and a plan for future compliance.

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

LICENSING EVALUATOR NAME:

Farhaan Sarangi

LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 04/03/2023 03:53 PM - It Cannot Be Edited

Created By: Farhaan Sarangi On 04/03/2023 at 03:01 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: ELSA'S HOME	FACILITY NUMBER: 496803960
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(d)(3)

Incidental Medical and Dental Care Services

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident files did not have a record for tracking the date and time PRN medication was taken, dosage taken, and the resident's response. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2023
	Plan of Correction
1 2 3 4	Plan of Correction (POC) shall include training staff on Medication Assessment Record (MARs), documentation and retaining the document. In addition, a plan for future compliance shall be submitted to CCL,.

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:

Hope DeBenedetti

LICENSING EVALUATOR NAME:

Farhaan Sarangi

LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC809 (FAS) - (06/04)

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