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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286802019
Report Date: 08/07/2024
Date Signed: 08/07/2024 05:35:20 PM

Document Has Been Signed on 08/07/2024 05:35 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LINDA FALLS GUEST HOME 1FACILITY NUMBER:
286802019
ADMINISTRATOR/
DIRECTOR:		SACRO, NORBERTFACILITY TYPE:
740
ADDRESS:755 LINDA FALLS TERRACETELEPHONE:
(707) 963-1440
CITY:ANGWINSTATE: CAZIP CODE:
94508
CAPACITY: 6CENSUS: 6DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:02 AM
MET WITH:Lino Caramat, CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:49 PM
NARRATIVE
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Licensing Program Analyst (LPA) J Macias arrived unannounced to conduct a required Annual inspection and was greeted by Staff/Caregiver. LPA contacted Administrator Norbert Sacro was not available to come during Annual Inspection and gave permission for caregiver to sign reports. Facility contact information was reviewed.Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six(6) residents in care. Facility approved/cleared for 3 ambulatory, 2 non-ambulatory, and 1 bedridden. One non-ambulatory, R2 resident is located on the second level of the facility, however fire clearance prohibits non-ambulatory residents on the second floor (deficiency cited, see 809D and *Civil Penalty Assessed*)

At approximately 9:30am, LPA and caregiver toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was not found to be stored in a safe manner with open items not labeled with opened date. Kitchen pantry containing bottled food contained multiple expired items (Kikkoman sweet cooking seasoning exp 12/4/2023, Organic coconut aminos sauce exp 7/6/2021, Worcestershire sauce exp 2/20/2021, Bulls Eye bbq sauce exp 10/11/2020, Sugarman Maple syrup exp 1/17/2020, Sweet chili sauce exp 4/9/2021, chili beans exp 4/21/23, Kraft Parmesan cheese exp 4/23/23 and 9/12/21(deficiency cited, see 809D). LPA observed kitchen pantry cabinet where food was stored to have multiple rodent droppings on every shelf, underneath the kitchen sink and where the potatoes were stored (deficiency cited, see 809D). Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care measured at 101.8, 103.6 degrees F, which is not within the allowable range of 105 to 120 degrees F. (deficiency cited, see 809D).

Fire extinguishers were last inspected May 1, 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills was conducted June 7 2024.

Continued on 809C...
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019
VISIT DATE: 08/07/2024
NARRATIVE
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Continued from 809...

At approximately 10:30am LPA conducted a review of 5 resident records. 4 out of the 6 residents, R2, R4, R5, R6 do not have current Appraisal Needs and Services Plan (LIC625) (deficiency cited, see 809D). R1 does not have a current LIC602 and an Appraisal Needs and Services Plan on file. (deficiency cited, see 809D).

At approximately 12:30pm LPA conducted review of (3) three staff records. LPA observed three out of three staff did not have required annual training on file (deficiency cited, see 809D).

At approximately 2:00pm LPA and Caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Facility does not have a current Centrally Stored Medication List on file for residents in care. (deficiency cited, see 809D)

Norbert Sacro Administrator Certificate 7006370740 expires 10/31/2024.



LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance
Current Lease

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

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/07/2024 05:35 PM - It Cannot Be Edited


Created By: Jacqueline Macias On 08/07/2024 at 04:10 PM
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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Per LPA observation and record review, the licensee did not comply with the section cited above in that one non-ambulatory, R2 resident is located on the second level of the facility, however fire clearance prohibits non ambulatory residents on the second floor, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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2
3
4
Licensee to ensure that residents retained are within fire clearance approval. Licensee to submit to CCL updated facility sketch showing all resident rooms with their current ambulatory/non-abulatory/bedridden status and submit an LIC200 in order to obtain fire clearance approval.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and record review, the licensee did not comply with the section cited above in that facility does not have a Centrally Stored Medication List on File for Residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Facilty to submit to CCL completed Centrally Stored Medication List for all residents in care by Plan of Correction due date of 8/8/2024. Additionally, facility to conduct medication training for Centrally Stored Medication Log by no later than August 29, 2024.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/07/2024 05:35 PM - It Cannot Be Edited


Created By: Jacqueline Macias On 08/07/2024 at 04:10 PM
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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in that water temperature in sinks accessible to residents in care measured at 101.8, 103.6, 138.2 degrees F, which is not within the allowable range of 105 to 120 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
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Facility to submit to CCL two week log of water temperature within regulation. Licensee to submit photos of thermometer readings along with temperature log. Picture of thermometer reading to include specific faucets being read.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that S1, S2, S3 had no required annual training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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2
3
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Facility to submit to CCL completed training certificates and/or training log for S1, S2, S3. Training log to include name of course, name of trainer, name of attendees, and course duration to CCL by POC due date.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/07/2024 05:35 PM - It Cannot Be Edited


Created By: Jacqueline Macias On 08/07/2024 at 04:10 PM
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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation the licensee did not comply with the section cited above in that LPA observed the kitchen pantry cabinet to have multiple food items to be expired. (Kikkoman sweet cooking seasoning exp 12/4/2023, Organic coconut aminos sauce exp 7/6/2021, Worcestershire sauce exp 2/20/2021, Bulls Eye bbq sauce exp 10/11/2020, Sugarman Maple syrup exp 1/17/2020, Sweet chili sauce exp 4/9/2021, chili beans exp 4/21/23, Kraft Parmesan cheese exp 4/23/23 and 9/12/21). Refrigerated food was not found to be stored in a safe manner with open items not labeled with opened date which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Facility to submit an LIC9098, self certifying that all perishable items in kitchen pantry are not past the best by due date and to label food items with date when opened.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that LPA observed kitchen pantry cabinet where food was stored to have multiple rodent droppings on every shelf, underneath the kitchen sink and where the potatoes were stored which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Facility to submit to CCL service work order from Pest Control company for vermin and rodent service. Facility to submit paid invoice along with work order. Service work order and paid invoice must be on Pest Control company professional letterhead. Facility to submit photos of pantry without all the rodent droppings by POC due date.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 08/07/2024 05:35 PM - It Cannot Be Edited


Created By: Jacqueline Macias On 08/07/2024 at 04:10 PM
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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in that R2, R4, R5, R6 do not have a current Appraisal Needs and Services Plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/21/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL current Appraisal Needs and Services plan for R2, R4, R5, and R6 by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in R1 does not have a current LIC602 and Appraisal Needs and Services Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL current Appraisal Needs and Services Plan and LIC602 by POC due date.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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