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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496890049
Report Date: 12/10/2020
Date Signed: 12/10/2020 04:33:28 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:EXCEPTIONAL CARE HOMEFACILITY NUMBER:
496890049
ADMINISTRATOR:JONES, RICHARDFACILITY TYPE:
740
ADDRESS:393 BONNIE AVENUETELEPHONE:
(707) 205-1228
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 3DATE:
12/10/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Orlando MadridTIME COMPLETED:
04:45 PM
NARRATIVE
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At approximately 12:45PM, Licensing Program Analyst’s (LPA’s) F. Sarangi and C. Arnhold arrived at this facility to conduct a Case management Legal/NCC visit and met with caregiver Orlando Madrid. LPA’s were not asked questions for a COVID-19 wellness screening at the door before entering the facility. There was no area set aside for checking staff temperature upon arrival to facility. LPA’s toured the facility and found it to be clean and in good condition. LPA’s observed a trip hazard in the floor of the hallway. The hole is approximately 8” long and 3” wide and approximately 1/4" deep. in the center of the hallway. LPA’s observed the medication closet was unsecured at the time of this visit. LPA’s observed a bottle of Lysol toilet cleaner unsecured, under the sink in the hallway resident bathroom. LPA’s observed cleaning materials stored in the garage, however the door to the garage was not secured. Upon further inspection, the door leading into the garage does not latch correctly. The garage contained normal storage items and a couch. Facility received a shipment of PPE supplies during this visit. Facility has PPE supplies to last 30 days. Food supplies are stored in the garage and kitchen cabinets. Facility will be restocking food stores 12/11/2020. Facility currently has the required supply of food items.

At approximately 1:45PM, LPA’s reviewed records. Staff training records were not available. Staff have not received training this year.

At approximately 2:00PM, LPA’s reviewed 3 of 3 resident records. 1 out of 3 resident records did not contain a current physician report. 3 out of 3 resident records did not contain a current resident appraisal.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.


This report was reviewed with Orlando Madrid and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2020
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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: EXCEPTIONAL CARE HOME
FACILITY NUMBER: 496890049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2020
Section Cited

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Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not
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met as evidenced by: Based on observations, the door of the medication closet was unsecured. This poses an immediate health and safety issue for residents in care.
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Training material and attendance roster to be submitted to CCL by POC date of 12/31/2020.
Type A
12/11/2020
Section Cited

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Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This
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requirement is not met as evidenced by: Based on observation, a bottle of cleaning liquid was stored unsecured under a resident bathroom sink. This poses an immediate risk to residents.
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Training to be scheduled by POC date of 12/11/20. Training material and attendance roster to be submitted to CCL by POC date of 12/31/2020.
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: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2020
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: EXCEPTIONAL CARE HOME
FACILITY NUMBER: 496890049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2020
Section Cited

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The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Based on observation, there is a hole in the middle of the hallway floor, causing
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a tripping hazard for residents. This poses an immediate safety risk for residents in care.
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Photo of completed repair to be submitted by POC date of 12/16/2020.

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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: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: EXCEPTIONAL CARE HOME
FACILITY NUMBER: 496890049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2020
Section Cited

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The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff...when there is significant change in the resident’s condition, or once every
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12 months, whichever occurs first. This requirement is not met as evidenced by: based on record review, 3 of 3 resident appraisals were not current. This poses a potential risk to residents.
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Type B
12/31/2020
Section Cited

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Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually. This requirement is not met as
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evidenced by: Based on records review 1 of 3 residents did not have a current medical assessment. This poses a potential health risk to residents in care.
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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: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2020
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: EXCEPTIONAL CARE HOME
FACILITY NUMBER: 496890049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2020
Section Cited

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Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on record review, Licensee did not
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document staff training. This poses a potential risk to residents in care.
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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: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2020
LIC809 (FAS) - (06/04)
Page: 5 of 5