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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800849
Report Date: 02/14/2022
Date Signed: 02/16/2022 10:21:19 AM

Document Has Been Signed on 02/16/2022 10:21 AM - 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:CEDARS DANTE HOUSEFACILITY NUMBER:
216800849
ADMINISTRATOR:MAYEEN GALANGFACILITY TYPE:
740
ADDRESS:1914 NOVATO BLVDTELEPHONE:
(415) 897-0817
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 6CENSUS: 6DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Renaud Michaud - staffTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Renaud Michaud. Some clients were present at the facility. Some clients at this facility are in day program and/or zoom activities. There are activities planned for clients during the day if they want to participate.

LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 2/14/2022 with staff Renaud facility was found at a comfortable temperature with all exits free from obstruction. Sample of client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 02/2021 at the time of the visit. Carbon monoxide detector wasn’t operational during visit. (see LIC 809-D) Sample test of Smoke detectors was conducted and were operational during this visit. 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 on this day at the time of the visit. Toxins are stored in a locked cabinet inside hallway closet. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. Client’s bedrooms that were inspected had lighting & appropriate furnishings; mattress pads are available for clients at the facility. Facility hot water temperature in clients' bathroom faucets measured between 107.2 degrees F and 109.2 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster Drills have been conducted with the last one being conducted on 1/5/2022.



Continue LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2022
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: CEDARS DANTE HOUSE
FACILITY NUMBER: 216800849
VISIT DATE: 02/14/2022
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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility, small table with hand sanitizer and other items designated for visitors are at entrance. Staff before coming into work has temperature checked. Facility has PPE supply stored in hallway closet, office room, and garage. There has been no new staff hired or new clients since COVID-19. Clients’ medications are stored and locked in medication cabinet inside office room. Facility has a 30-day supply of medication for clients. Clients are sometimes wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. Staff had masks on during this visit. Clients have available zoom and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and staff had N-95 fit testing conducted.

Appeal of Rights Given.

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.


Department is requesting Licensee to update the following documents and submit to CCL by 2/21/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 400 Affidavit Regarding Resident Cash Resources
LIC 402 Surety Bond (if applicable)
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrator's Certificate
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2022 10:21 AM - It Cannot Be Edited


Created By: Carla Fernandes-Goes On 02/14/2022 at 11:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CEDARS DANTE HOUSE
FACILITY NUMBER: 216800849

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interview, the licensee did not comply with the section cited above in 1 out of 1 carbon monoxide which poses/posed a potential health, safety or personal rights risk to persons in care. During visit LPA tested carbon monoxide and learned that carbon monoxide wasn't working; staff changed battery on carbon monoxide and it didn't work.
POC Due Date: 02/28/2022
Plan of Correction
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Faciity to ensure that carbon monoxide is present and working properly at all times. Facility to replace carbon monoxide and submit a self-certification that carbon monoxide is working properly at facility by POC date of 2/28/2022. Staff was able to present LPA with a working carbon monoxide during this visit at 12:16 PM. POC Cleared
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Moellers
LICENSING EVALUATOR NAME:Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022


LIC809 (FAS) - (06/04)
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