496804143-5-13-2024-21-AS-SHAN-D58UJP-20240513153751

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804143
Report Date: 05/13/2024
Date Signed: 05/13/2024 03:38:00 PM

Document Has Been Signed on 05/13/2024 03:38 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:	SENIOR CARE LIVING		FACILITY NUMBER:	496804143
ADMINISTRATOR:	SORENSEN, JANINE		FACILITY TYPE:	740
ADDRESS:	1960 DENNIS LANE		TELEPHONE:	(707) 304-4790
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 6	DATE:	05/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensee, Ami Kumar & Administrator, Janine Sorensen		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Hansen conducted an unannounced Annual inspection of facility and met with Ami Kumar, Licensee and Janine Sorenson, Administrator. Facility has 6 residents in care, 2 receiving hospice care and 5 residents with dementia diagnosis.

At approximately 11:10 AM LPA & Administrator toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All residents have call buttons and motion sensors which sound in kitchen area. All notices that are required to be posted have been posted and are in a highly visible area. Facility has an approved dementia plan of operation. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in locked laundry room, hallway closet and under locked kitchen sink. Water temperature measured between 127.2 degrees F to 128.8 degrees F falling out of regulation between 105 and 120 degrees F in 5 out of 5 faucets accessible to residents in care. Licensee turned water heater down at time of visit. (see LIC809-D) There was an ample supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. Fire extinguisher inspected was last charged on 12/28/2023. Smoke detectors and carbon monoxide detectors were tested and found to be in working order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in med room off of kitchen which also contains a small refrigerator with lock for medication.

Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.”

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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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Document Has Been Signed on 05/13/2024 03:38 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SENIOR CARE LIVING	FACILITY NUMBER: 496804143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in 1 out of 5 staff did not have TB test/ results which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2024
	Plan of Correction
1 2 3 4	Licensee to have staff (S1) obtain a TB test and submit copies to Community Care Licensing for review by POC due date 05/17/2024. Licensee to notify CCL if more time is needed.

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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: SENIOR CARE LIVING	FACILITY NUMBER: 496804143
	VISIT DATE: 05/13/2024

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At approximately 12:30 PM, LPA reviewed 5 of 5 resident records and found 5 of 5 residents have current physician’s reports and updated care plans. 5 of 5 resident records contained current and signed admission agreements and physician’s orders on file. Hospice care plans are up to date and current.

At approximately 1:50 PM, LPA review 5 of 5 staff records. 5 of 5 records contain documentation of completed training records as required. Evidence of current first aid and CPR training were observed. Staff S1 records did not contain current TB (see LIC809-D).

The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 5/13/2024 at 2:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

At approximately 12:30 PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts quarterly disaster drills with the last disaster drill conducted on 4/15/2024. Janine Sorrenson Administrator Certificate #6039492740, expired 5/4/2024 and provided LPA confirmation of pending certificate. LPA reviewed Licensing Information System (LIS) with Licensee who stated that is corrected and updated at this time; no need to change any of the information.

Appeal Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.
LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 6/5/2024:

LIC 308 Designation of Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changed)
LIC 9020 Register of Facility /Resident’s
Control of Property – Lease or Deed
Copy of Administrator’s 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: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/13/2024 03:38 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: SENIOR CARE LIVING	FACILITY NUMBER: 496804143
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that the water temperature tested in resident's bathrooms ranged from 127.2 degrees F to 128.8 degreeses F, this poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Licensee lowered the water temperature during inspection. Licensee to submit a log of water temperature from 5/14/2024 to 5/31/2024. Licensee to submit a written statement that they understand the regulation and will be in future compliance by POC due date 05/31/2024

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC809 (FAS) - (06/04)

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