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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804108
Report Date: 12/27/2023
Date Signed: 12/28/2023 08:29:20 AM


Document Has Been Signed on 12/28/2023 08:29 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:ANGEL'S PLACE IN MOSSWOOD PLACEFACILITY NUMBER:
496804108
ADMINISTRATOR:DICHOSO, ALMAFACILITY TYPE:
740
ADDRESS:311 MOSSWOOD LANETELEPHONE:
(707) 708-2694
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 5DATE:
12/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alma Dichoso, AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Alma Dichoso, Administrator. Facility currently has five residents, one of which is on hospice, which is allowable per the facility's Hospice Waiver for 4. Facility contact information was reviewed.

At approximately 9:15am LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was not found to be stored in a safe manner. Rice cooked on the day of December 26, 2023 was left out overnight and half of the next day at room temperature. Per Title 22 regulation 87555(b)(23) - General Food Service Requirements (b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures (deficiency cited, see 809D).

Kitchen cabinet under sink containing cleaning supplies and disinfectants was not locked. Per Title 22 Regulation 87705(f)(2): 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 (deficiency cited, see 809). Per LPA interview with Administrator, kitchen sink is leaking such that a basin approximately 9 inches deep is placed under leak to catch water. Per Administrator, the basin requires emptying every couple of days. Per Administrator, repair technician is scheduled to come and fix the leak the week of January 1, 2024. Per Title 22 regulation 87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors (deficiency cited, see 809D).

Report continued on LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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 5


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: ANGEL'S PLACE IN MOSSWOOD PLACE
FACILITY NUMBER: 496804108
VISIT DATE: 12/27/2023
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Continued from 809...

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 106.2 and 115.3 degrees F which is within the allowable range of 105 to 120 degrees F.

Fire extinguishers were last inspected January 6, 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on October 27, 2023.

At approximately 11:30am LPA conducted a review of 5 out of 5 resident files and 4 out of 4 staff records. All required documents current. At approximately 2:00pm LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet in the hallway.

Alma Dichoso, Administrator Certificate 6063184740 expired 06/02/2024. LPA and Licensee discussed facility's Infection Control Plan and Emergency Disaster Plan, no updates at this time.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC308- Designation of Responsibility
Evidence of Liability Insurance

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

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/28/2023 08:29 AM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ANGEL'S PLACE IN MOSSWOOD PLACE
FACILITY NUMBER: 496804108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Administrator interview, the licensee did not comply with the section cited above as rice cooked on the day of December 26, 2023 was left out overnight and half of the next day at room temperature, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Admin discarded rice immediately. Admin will submit to CCL a LIC9098 certifying that all food will be labled and stored within regulation.
Type A
Section Cited
CCR
87705(f)(2)
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 LPA observation the licensee did not comply with the section cited above in [1] out of [1] kitchen cabinet under sink containing cleaning supplies and disinfectants was not locked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/28/2023
Plan of Correction
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Admin will submit to CCL a LIC9098 certifying all staff will keep kitchen cabinet under sink, and all cabinets and containers, containing cleaning supplies and disinfectants locked and contents inaccessible to residents in care.
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 12/28/2023 08:29 AM - 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: ANGEL'S PLACE IN MOSSWOOD PLACE
FACILITY NUMBER: 496804108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Administrator interview, the licensee did not comply with the section cited above in [1] of [1] kitchen sink. Kitchen sink is leaking such that a basin approximately 9 inches deep is placed under leak to catch water. Per Administrator, the basin requires emptying every couple of days, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/08/2024
Plan of Correction
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Per Administrator, repair technician is scheduled to come and fix the leak the week of January 1, 2024. Admin to submit to CCL a repair invoice showing completed repair of leak under kitchen sink by plan of correction due date.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5