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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804133
Report Date: 07/18/2024
Date Signed: 07/18/2024 03:44:51 PM


Document Has Been Signed on 07/18/2024 03:44 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:RINCON VALLEY ASSISTED LIVING LLCFACILITY NUMBER:
496804133
ADMINISTRATOR:GURJA, FIKREFACILITY TYPE:
740
ADDRESS:996 ESTES DR.TELEPHONE:
(707) 235-8007
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 3DATE:
07/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:CaregiverTIME COMPLETED:
03:59 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver (S1). Caregiver (S2) arrived later. Administrator Fikre Gurja was contacted by phone. Admin out of the country. Admin gave caregiver S2 permission to sign. Facility contact information was reviewed. Facility staff roster was reviewed. S1 not associated to the facility. S1 has been working at facility since October of 2023. In addition to not being associated to the facility, S1 also does not have fingerprint clearance. Per Guardian background check system, S1 has an incomplete application and was notified of such on 9/17/2023 (deficiency cited, see 809D and *civil penalty assessed* in the amount of $500). LPA advised S2 and S1 that S1 must leave the facility and not return to work or provide any care to residents until fingerprint clearance is obtained and they are associated to the facility.

At approximately 9:30 am LPA 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. LPA and caregiver observed package of Keebler Club crackers opened but not covered or labeled with date opened. Canned goods found to be stamped with expired Best If Used By (BIUB) dates: one can of Bruce's Yam 12/22/2023, one bottle of Hidden Valley Ranch dressing 5/30/2024, two [2] cans of S&W garbanzo beans 11/18/2023, one can of Swanson's chicken broth 11/11/2023. Frozen beef steak dated 10/27/2023 (deficiency cited, see 809D). Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives was open but has locking function.

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 bathroom had required bath mat and grab bars. However, mats in all 3 resident bathrooms were found to have black and brown substance on the underside of the mat, two of which had the substance almost covering the entire surface, one of which had varied spotting of the black substance (deficiency cited, see 809D).

Continued on 809C...
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133
VISIT DATE: 07/18/2024
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Continued from 809...

Water temperature in sink accessible to residents in care measured at 116.9, 119.4, and 119.4 degrees F which is within the allowable range of 105 to 120 degrees F. LPA advised caregiver that the 119.4 is very close to the maximum allowable temperature of 120 degrees F, so licensee may consider turning down the water heater slightly as a preventative measure.



Fire extinguishers were last inspected 6/19/2024. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 6/25/2024. Facility has a backup generator for use during a power outage

At approximately 11:30am LPA conducted review of 5 staff records. All required documentation present.

At approximately 1:30pm LPA conducted a review of 3 resident records. R1 has DX of dementia but most recent medical assessment dated 11/11/2022 and most recent appraisal dated 8/20/2022 (deficiency cited, see 809D)

At approximately 2:00pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. During spot check of medication, LPA and S2 observed: R2 to have prescription for Lisnopril rx#161458369 to be missing fill date on Centrally Stored Medication log (CSML). R3 had bubble pack of Tramodol with no start date but 3 pills missing. Per caregiver, bubble pack arrived with resident upon move in, but has not taken any since admission, but no notes on CSML indicating as such. LPA advised that some note must be made to account for missing pills. R2 had prescription for Quetiapine in the amount of 300 mg daily (100mg in the morning and 200mg at night), LPA and caregiver observed a count of 50 remaining in the bottle with an original fill quantity of 90, start date was 6/28/2024 and fill date was 5/23/2024. Count was off, indicating missed doses. Caregiver explained that on 5/17/2024 and 6/24/2024 the prescribed dose was changed. LPA advised 5/17/24 is before fill date of 5/23/24, so prescription should have been changed before filling in order to ensure accurate fill, accurate dosing, and accurate entry on CSML (deficiency cited, see 809D).

Continued on 809C(2)...

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 2 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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133
VISIT DATE: 07/18/2024
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Continued from 809C...

Fikre Gurja Administrator certificate #7029598740 exp 1/7/2025


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

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Current Lease

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. *Civil Penalty assessed* Appeal rights given and discussed with caregiver S2. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with caregiver S2 and a copy of this report was given.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 07/18/2024 03:44 PM - 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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S1 not associated to the facility. S1 has been working at facility since October of 2023. In addition to not being associated to the facility, S1 also does not have fingerprint clearance. Per Guardian background check system, S1 has an incomplete application and was notified of such on 9/17/2023, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Facility to submit to CCL written confirmation and self-certifying LIC9098 that S1 will not return to the facility or provide any care to residents until fingerprint clearance is obtained and they are associated to the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 07/18/2024 03:44 PM - 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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that mats in all 3 resident bathrooms were found to have black and brown substance on the underside of the mat, two of which had the substance almost covering the entire surface, one of which had varied spotting of the black substance, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Facility threw away all 3 mats with LPA present at facility. Facility to provide CCL with pictures of clean mats present in each resident bathroom by plan of correciton due date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that LPA and caregiver observed package of Keebler Club crackers opened but not covered or labeled with date opened. Canned goods found to be stamped with expired Best If Used By (BIUB) dates: one can of Bruce's Yam 12/22/2023, one bottle of Hidden Valley Ranch dressing 5/30/2024, two [2] cans of S&W garbanzo beans 11/18/2023, one can of Swanson's chicken broth 11/11/2023. Frozen beef steak dated 10/27/2023 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Facility discarded all items with LPA present at facility. Deficiency cleared.
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 BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 07/18/2024 03:44 PM - 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: RINCON VALLEY ASSISTED LIVING LLC
FACILITY NUMBER: 496804133

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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3
4
Based on LPA and caregiver observation and record review, the licensee did not comply with the section cited above in that LPA and S2 observed: R2 to have prescription for Lisnopril RX161458369 to be missing fill date on Centrally Stored Medication log (CSML). R3 had bubble pack of Tramodol with no start date but 3 pills missing. Per caregiver bubble arrived with resident upon move in, but has not taken any since admission, but no notes on CSML indicating as such. LPA advised that some note must be made to account for missing pills. R2 had prescription for Quetiapine in the amount of 300 mg daily (1 in the morning and 2 at night), LPA and caregiver observed a count of 50 remaining in the bottle with an original fill quantity of 90, start date was 6/28/2024 and fill date was 5/23/2024. Count was off, indicating missed doses. Caregiver explained that on 5/17/2024 and 6/24/2024 the prescribed dose was changed. LPA advised 5/17/24 is before fill date of 5/23/24, so prescription should have been changed before filling in order to ensure accurate fill, accurate dosing, and accurate entry on CSML, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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3
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Facility to conduct medication training with all staff by plan of correction due date and submit to CCL either completed certificates or completed training log for said training. Training log to include name of trainer, duration of course in hours, staff attendees and name of course.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA observation and record review, the licensee did not comply with the section cited above in that R1 most recent 602 dated 11/11/2022, most recent ANS dated 8/20/2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Facility to submit pictures of current medical assessment and appraisal for R1 by plan of correction due date.
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 BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8