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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804156
Report Date: 08/17/2023
Date Signed: 08/17/2023 02:52:09 PM

Document Has Been Signed on 08/17/2023 02:52 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:PENNGROVE GARDENSFACILITY NUMBER:
496804156
ADMINISTRATOR:CARDENAS, CRISANTEFACILITY TYPE:
740
ADDRESS:1895 ALAN DRIVETELEPHONE:
(707) 327-6968
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY: 8CENSUS: 7DATE:
08/17/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lisa Cortez, Licensee & Chrisante Cardenas, Licensee/Administrator & Licensee/Admin Claudia QuijadaTIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Hansen conducted a pre-licensing inspection and met with Administrator Crisante Cardenas, Licensee, Lisa Cortez & former Licensee/Administrator Claudia Quijada. Fire clearance has been approved for 8 residents (5 non-ambulatory and 3 bedridden) by the County Fire Department. LPA will conduct a component III orientation with Crisante Cardenas, Administrator. There is a total of 7 residents with 1 under Hospice care and 7 with dementia diagnosis.

Facility tour/inspection began at 11:05 AM:
Facility is a two-floor facility. LPA toured the facility on 8/17/2023 with Administrator Crisante C. former licensee Claudia Quijada arrived shortly after; facility was found to be at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on 3/3/2023. Sample test of facility smoke detectors and carbon monoxide detectors were found to be operational. Sample hot water temperature measured between 114.4 degrees F and 121.6 degrees F. falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 5 of 5 resident’s bathroom faucets (citation on existing license). The facility has special care plan of operation and programming for residents with dementia. 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. LPA observed that provisions are made for individuals with special dietary needs; facility has a board in the kitchen with residents' name & a list of dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents posted. Toxins are stored in a locked closet in the office room on the side of the facility. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Mattress pads are available for residents.
Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
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: PENNGROVE GARDENS
FACILITY NUMBER: 496804156
VISIT DATE: 08/17/2023
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The main floor includes kitchen, laundry room, living room area, bathrooms, office room, dining room, and resident's bedrooms, and bathrooms; second floor is used as staff living quarters. Facility activity calendar is posted by the dining room as well as a menu, posted in the kitchen. There is outdoor space for activities. Resident's & Personnel records, medication, first aid supplies, and toxins are locked in the office; although at 11:10 am LPA & Administrator Chris C observed kitchen drawer, with broken lock containing pre-poured medications for all residents (citations on existing license). Postings noted to be current and in compliance with guidelines. Locked cabinets for sharps and daily used toxins located in office room. First aid kit has been placed by medications.

Disaster Drills have been conducted quarterly and in different shifts with the last one being conducted on 7/20/2023. Administrator Certificate for Chrisante Cardenas # 6025751740 expired on 3/24/2023 and renewal is currently pending.

Community Care Licensing has requested the following items be corrected prior to licensure:

- Provide 7 day log of water in all residents bathroom faucets are within regulations and signed training sheet of all staff regarding locked medications & medications to be kept in original containers. LPA observed facility has removed medications from kitchen cabinet & turned water heater down prior to end of visit.

LPA completed COMP III with Administrator Chrisante Cardenas.

See Existing License 896803989 for citations issued during today’s Pre-Licensing



LPA will conduct record review and medication review during Post Licensing

LPA will notify Application Unity of today’s inspection
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2023
LIC809 (FAS) - (06/04)
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