496890095-11-2-2023-21-AS-DALO-CX7UEE-20231102153101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496890095
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:32:04 PM

Document Has Been Signed on 11/02/2023 03:32 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:	ALLURE SENIOR CARE		FACILITY NUMBER:	496890095
ADMINISTRATOR:	SHAUGHNESSEY, MERA		FACILITY TYPE:	740
ADDRESS:	2008 DENNIS LANE		TELEPHONE:	(707) 843-4090
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	6	CENSUS: 6	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Mera Shaughnessey-Administrator		TIME COMPLETED:	03:30 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) Alviso conducted a Required- 1 Year visit, on 11/2/23 at approximately 9:50am, and met with Licensee/Administrator Mera Shaughnessey. There are currently six(6) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for three(3)residents. Facility has an infection control plan as required. Facility has an emergency and disaster plan as required. The facility conducted a fire drill and an earthquake emergency drill on 7/8/23. Facility does have a generator for emergencies if needed. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Facility has a fire clearance approval by the Santa Rosa Fire Department for a total of six non-ambulatory and/or bedridden-effective 12/5/2022. Al exits were free and clear of obstruction. Fire extinguishers, two(2), were serviced and tagged as required-expires 12/5/23. There are nine(9) smoke alarms that are also carbon monoxide detectors. All smoke alarms,, including the hallway fire door worked appropriately during the inspection. All exit doors had auditory alarms and the alarms were working properly during the inspection. The backyard has outside patio furnishings for resident use, including areas providing shade for residents as needed. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed; Every resident room has a bathroom that is able to provide showers as needed. There is a large bathroom with a open roll-in shower for resident use as needed. Facility has a sufficient supply of personal protective equipment(PPE).. LPA observed sufficient supply of food, perishable and non-perishable. Facility had sufficient furnishings for residents in care, and the fcility has sufficient lighting in all rooms, bathrooms, and common areas, including night lights. Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 3

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: ALLURE SENIOR CARE	FACILITY NUMBER: 496890095
	VISIT DATE: 11/02/2023

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
26
27
28
29
30
31
32

Medications were centrally stored, and locked up making them inaccessible to residents in care. Toxins/cleaners were locked up making them inaccessible to residents in care.

LPA reviewed six (6) resident files; All resident files were found to be complete.

LPA reviewed five(5) of five(5) staff files. LPA reviewed staff training. All five(5) staff have criminal record clearance, and are associated as required. All staff had required training. All staff had current First Aid and CPR Certification.

LPA is requesting the following documents be updated and submitted by 12/2/23:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate

During the inspection, the LPA observed several food items that were not covered and stored appropriately to protect the safety and acceptability necessary to prevent contamination, including a package of salami that was covered in mold, soup that was out of date per label and not able to be consumed, and a package of beef meat that was half used and stored inappropriately covered, this deficiency will be cited, 87555(b)(9) Food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Appeal rights given to the Administrator.
Exit interview conducted with Licensee Mera Shaughnessey..

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/02/2023 03:32 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: ALLURE SENIOR CARE	FACILITY NUMBER: 496890095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(9)

87555(b)(9) Food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observed several food items in the refrigerator that were not covered and stored appropriately to protect the safety and acceptability necessary to prevent contamination; observed items, a package of salami that was covered in mold, soup that was out of date per label and not able to be consumed, and a package of beef meat that was half used and stored inappropriately covered, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/03/2023
	Plan of Correction
1 2 3 4	Licensee to ensure the refrigerator is cleaned and all items that are not stored appropriately, per regulations, are discarded. Ensure an in-service with staff regarding policy and procedures on Food Service, including storage of food items per regulation 87555. Submit proof of training, and plan on maintenance for the facility to remain in compliance by 11/7/23. Submit Plan of correction due by 11/3/23

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3