496804028-2-24-2023-21-AS-SHAN-CPCRSW-20230224121726

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804028
Report Date: 02/24/2023
Date Signed: 02/24/2023 12:17:32 PM

Document Has Been Signed on 02/24/2023 12:17 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:	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:	02/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Staff, Kathlyn Ligalevu		TIME COMPLETED:	12:20 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	License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required – 1 yr. Infection Control Inspection of the facility. LPA was welcome by staff Meliki. Facility has 6 residents with 1 under hospice care at this time and 2 with dementia. LPA conducted inspection with Kathlyn Ligalevu after speaking on the phone with Administrator, Dharmisthaben Patel who was unavailable. 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 2/24/2023 with staff Kathlyn Ligalevu, 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 03/02/22. Facility Smoke and Carbon Monoxide detectors were found to be operational. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day. Hot water temperature measured between 109.2 degrees F to 119.1 degrees F in 5 out of 7 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 residents in care. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms 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. 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 centrally stored and locked on kitchen draws. Disaster Drills have been conducted by monthly and last dated 12/16/22. Infection Control: Facility has submitted a mitigation program plan and infection control plan. 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. Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

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: TREEHOUSE SENIOR LIVING	FACILITY NUMBER: 496804028
	VISIT DATE: 02/24/2023

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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 residents have available virtual and telephone calls when contacting with family members and others. Facility has acquired N-95 fit testing and received PPE training.

LPA reviewed Licensing Information System (LIS) with designee who stated that is corrected and updated 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.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.
Administrator Certificate is for Dharmisthaben Patel # 6033357740 Exp. 01/08/2023 resubmitted 11/2022 will send updated Admin Certificate when receive.
All staff have received COVID booster vaccinations and inclusively work at this facility.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 3/7/2023 to SRRO:

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 Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023

LIC809 (FAS) - (06/04)

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