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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 570314689
Report Date: 07/27/2021
Date Signed: 07/27/2021 03:09:33 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:SACRED HEART CARE HOME FOR THE ELDERLYFACILITY NUMBER:
570314689
ADMINISTRATOR:DAVIS, ARVINFACILITY TYPE:
740
ADDRESS:605 CONNOR LANETELEPHONE:
(530) 662-6055
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:8CENSUS: 6DATE:
07/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator, Arvin DavisTIME COMPLETED:
03:15 PM
NARRATIVE
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On 7/27/21 at approximately 1:50 PM Licensing Program Analysts (LPAs) Walters and Nakagawa conducted a Case Management inspection with Administrator, Arvin Davis. This facility is currently in the process of changing ownership. This facility is still licensed as Sacred Heart Care Home for the Elderly. Administrator, Arvin Davis will be the Administrator once the licensure is complete. While conducting a change of ownership pre-licensing inspection LPAs observed areas of non-compliance.

The following areas of non-compliance were observed:
  • Hot water temperature measured at 136.2, 136.7 and 142.3, which is not within requirements of 105 to120 degrees. (pictures taken)
  • Sharps were accessible to residents with dementia. (pictures taken). Administrator immediately removed and locked all sharps.

The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SACRED HEART CARE HOME FOR THE ELDERLY
FACILITY NUMBER: 570314689
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2021
Section Cited

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87303(e)(2)Fixtures, Furniture Equipment and Supplies.Hot water .. used by clients shall attain a hot water temperature of..105degrees F& not more than 120 degrees F This requirement is not met as evidenced by:
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Based on observation the licensee didn't comply w/this section above hot water in 3 faucets measured at 136.2,142.3 and 136.7 which poses a immeditely health, safety risk to clients in care.
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bathroom's faucet & submit log to CCL attention Jill Nakagawa by the date of 8/3/2021.
Type A
08/03/2021
Section Cited

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87705 CARE OF PERSONS WITH DEMENTIA. The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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***Based on statements made and observation, this requirement not met as evidenced by: Knives were not secure. LPAs observed knives in the unlocked kitchen drawer, which was accessible to residents with dementia. This poses an immediate health and safety 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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina WaltersTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2021
LIC809 (FAS) - (06/04)
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