496804138-1-31-2024-21-AS-CCOO-CZZVRT-20240131154026

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804138
Report Date: 01/31/2024
Date Signed: 01/31/2024 03:40:57 PM

Document Has Been Signed on 01/31/2024 03:40 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:	TAKING THE JOURNEY NORTH		FACILITY NUMBER:	496804138
ADMINISTRATOR:	ERIKSEN, KELLY		FACILITY TYPE:	740
ADDRESS:	2125 MCSWEEN LN		TELEPHONE:	(707) 338-8812
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 6	DATE:	01/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Kelly Eriksen, Administrator		TIME COMPLETED:	03:36 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) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Kelly Eriksen arrived later. Facility currently has two [2] residents on hospice which is allowable per the facility's Hospice Waiver for two [2]. One resident is bedridden and resides in bedroom with bedridden fire clearance per STD850. At approximately 9:30am LPA and Admin 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 found to be stored in a safe manner with open items covered and labeled. Kitchen cabinet containing cleaning supplies and sharp knives was locked. All bedrooms were equipped with lighting/lamp, 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 112 and 110.5 degrees F, respectively which is within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 1/29/2024. 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 1/12/2024. Facility has a backup generator for use during a power outage. At approximately 11:35am LPA conducted a review of six [6] out of six [6] resident files. All required documents present. Continued on 809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TAKING THE JOURNEY NORTH	FACILITY NUMBER: 496804138
	VISIT DATE: 01/31/2024

NARRATIVE

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Continued from 809...

At approximately 1:15pm LPA conducted a review of five [5] out of five [5] staff files. Two [2] out of five [5] staff members did not have the required number of hours completed. Staff (S1) and (S2) are in their first year of employment and have completed 16 hours of training. Per Health and Safety Code 1569.625 - Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required... (deficiency cited, see 809).

At approximately 2:30pm LPA and Admin conducted a spot check of medication and medication records. No discrepancies observed. Medication is centrally stored in a locked closet in the hallway.

Kelly Eriksen Administrator Certificate 6027539740 expired 11/4/2023; however, Admin provided proof of Admin cert renewal docs submitted 1/19/2024. All fees are current as of this time. LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster plan. Licensee will send copy of updated Emergency Disaster plan to CCL within 30 days. No updates made to Infection Control Plan.

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
Emergency Disaster Plan
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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/31/2024 03:40 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: TAKING THE JOURNEY NORTH	FACILITY NUMBER: 496804138
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(1)

Other Provisions

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in [2] out of [5] staff members. Staff (S1) and (S2) are in their first year of employment and have not completed total number of required training hours, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Admin to submit LIC9098 self-certifying total number of hours required of trianing have been completed in complaince with the above deficency for S1 and S2. Admin to submit along with LIC9098 a training log that depicts: completed hours, staff attendees, course name, and trainer.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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