496804028-7-18-2022-21-AS-CFGS-CGFL7T-20220718083053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804028
Report Date: 07/15/2022
Date Signed: 07/18/2022 08:30:58 AM

Document Has Been Signed on 07/18/2022 08:30 AM - 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:	TREEHOUSE SENIOR LIVING		FACILITY NUMBER:	496804028
ADMINISTRATOR:	PATEL, DHARMISTHABEN		FACILITY TYPE:	740
ADDRESS:	1879 ALAN DRIVE		TELEPHONE:	(707) 665-5624
CITY:	PENNGROVE	STATE: CA	ZIP CODE:	94951
CAPACITY:	10	CENSUS: 6	DATE:	07/15/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Pamela Lopez - staff		TIME COMPLETED:	01:00 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) Fernandes-Goes conducted an unannounced post-licensing infection control inspection to this facility and was welcome by staff Pamela Lopez. Facility has 6 residents with 2 under hospice care at this time. LPA arrived at the facility and observed hand sanitizer at the entrance and a log in binder for temperature of visitors and answering questionnaire. During tour the facility on 7/15/2022 with staff Pamela Lopez, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample tour of resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 03/22. Hot water temperature measured between 114.2 degrees F and 120 degrees F in 3 out of 3 resident’s bathroom faucets which are within Title 22 acceptable regulation of 105 to 120 degrees F. Toxins are stored in a locked laundry room. Dangerous items were stored inaccessible to develop disabled residents. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. Sample resident’s bedrooms have lighting & appropriate furnishings. Facility understands that unvaccinated and/or not fully vaccinated staff must have an exception on file and be tested once a week. Resident’s files have been updated under new facility as well as staff files. All required facility postings are in place. Resident’s medications are stored and locked on kitchen draws. Disaster Drills have been conducted monthly and last dated 07/01/22. Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

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: TREEHOUSE SENIOR LIVING	FACILITY NUMBER: 496804028
	VISIT DATE: 07/15/2022

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Infection Control:
Facility has submitted a mitigation program plan that has been approved at this time and infection facility program plan has been submitted. Posters have been placed at facility by entrance. Facility has PPE supply stored in the facility garage/storage room. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Facility is allowing visitors and clients have available virtual and telephone calls when contacting with family members and others. Facility has acquired N-95 fit testing.

There were no deficiencies cited at this time

Department is requesting the following to be submitted to CCLD by 7/22/2022:
LIC 500
LIC 9020
Copy of liability insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC809 (FAS) - (06/04)

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