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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486801137
Report Date: 09/12/2024
Date Signed: 09/12/2024 12:43:33 PM

Document Has Been Signed on 09/12/2024 12:43 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:ST. JOSEPH CARE HOME-BFACILITY NUMBER:
486801137
ADMINISTRATOR/
DIRECTOR:		HELEN RABAGOFACILITY TYPE:
740
ADDRESS:1405 DONNER PASS DRIVETELEPHONE:
(707) 980-7833
CITY:VALLEJOSTATE: CAZIP CODE:
94590
CAPACITY: 6CENSUS: 5DATE:
09/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:37 AM
MET WITH:Helen Rabago (Administrator)TIME VISIT/
INSPECTION COMPLETED:
12:58 PM
NARRATIVE
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Licensing Program Analyst (LPA) M. Cuadra conducted an unannounced Annual Required 1 Year inspection and met with Administrator Helen Rabago. There are residents receiving hospice services and diagnosis of dementia. Annual fees are current. Required postings were observed.

LPA/Administrator toured the facility inside and outside at approximate 10:00am and observed the following: Facility is clean, in good repair and at a comfortable temperature with all exits free from obstruction. Fire extinguisher charged and serviced February 2024. Smoke detectors and carbon monoxide detector were found to be all operational during the visit. Bathrooms were equipped with necessary grab bars and non-slip floors/mats. All three bedrooms used by residents did not have chairs as indicated per regulation. Administrator placed chairs on resident's rooms as stated per regulation (technical violation issued). Hot water temperature measured between 114.12 and 113.0 degrees F, in resident's bathrooms, which is within regulation of 105 to 120 degrees F. Last disaster drill was conducted on June 14, 2024. There is a minimum of one week supply of nonperishable foods and two days of perishable foods and it was stored and handled per regulation. However, during today's visit LPA did not observe any snacks been provided to residents in care. Per Administrator, sometimes they don't provide residents with morning snacks just afternoon. LPA discussed with Administrator that between meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. Also, LPA did not observed any activities been encouraged to residents. Per Administrator, sometimes they go outside to exercise. There was an ample supply of hygiene products and paper products available for residents. Medication centrally stored and locked. Auditory alarms were present and operational.
Continues on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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Document Has Been Signed on 09/12/2024 12:43 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 09/12/2024 at 12:06 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: ST. JOSEPH CARE HOME-B
FACILITY NUMBER: 486801137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s/Administrator observations and statements received, the licensee did not comply with the section cited above due to not having daily activities for residents as required, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Licensee to submit their plan to ensure residents are provided daily activities per regulation. Written statement signed by staff that staff understands this regulation. Detailed plan to be submitted to Community Care Licensing by POC due date 9/20/2024.
Type B
Section Cited
CCR
87555(b)
General Food Service Requirements
(b) The following food service requirements shall apply:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above by having ingredients available, but not offering residents snacks between morning meals as stated per regulation and their program plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Facility to send in written plan that will be followed, plan for snacks being available for residents to take and/or staff providing snacks to residents on a daily basis to residents, according to dietary restrictions and written statement signed by staff that staff understands this regulation POC Due date 9/20/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 09/12/2024 12:43 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 09/12/2024 at 12:06 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: ST. JOSEPH CARE HOME-B
FACILITY NUMBER: 486801137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

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
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in four out of five resident's care plans were not been performed within last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator agreed to review all resident's care plans, update them accordingly and send self-certification form (LIC9098) that this process had been done to CCL by POC due date of 9/20/2024.
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
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Based on LPA's/Administrator observation, interview and record review, the licensee did not comply with the section cited above in two out of five resident's medical assessments were not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator agrees to obtain resident's medical assessments and submit self-certification form (LIC9098) that this process had been done to CCL to clear POC by due date of 9/20/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/12/2024 12:43 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 09/12/2024 at 12:06 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: ST. JOSEPH CARE HOME-B
FACILITY NUMBER: 486801137

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) 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).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Administrator observation and interview, the licensee did not comply with the section cited above due to observed unlocked sharps on top of facility's fireplace, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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Administrator to ensure that all sharp objects are stored in a locked storage inaccessible to residents at all times. Administrator to submit an LIC 9098 self certification that all items that can constitute danger to residents have been made inaccessible to residents in care to CCL by POC of 9/20/24.
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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2024


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: ST. JOSEPH CARE HOME-B
FACILITY NUMBER: 486801137
VISIT DATE: 09/12/2024
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Continued from LIC809...

During tour of the facility LPA/Administrator at approximate 10:30am observed a container of sharps including needles was sitting on top of the fireplace accessible to residents in care. Administrator removed the container immediately and placed it in the garage.

At approximate 10:45am LPA initiated file review. Five resident's and three staff files were reviewed. Two out of five residents who has a diagnosis of dementia do not have a current medical assessment. Four out of five resident's (R1, R2, R3 & R4) care plans needs were updated, but not signed by their responsible party. LPA/Administrator discussed the importance of having resident's responsible party to acknowledge any changes of care plans. Resident (R5) sharing room with a person who is terminally ill does not have a current agreement to grant access to the shared living space to others on file (technical violation issued). Staff have required CPR/1st aid certificates and additional training hours. Administrator Certificate of Helen Rabago #6021326740 expires 10/28/2024. Medication and medication records were reviewed. Contact information was reviewed.

Administrator agreed to submit copies of the following by not later than 9/20/24:
LIC 308 Designation of Administrative Responsibility, LIC 500 Personnel Summary, LIC 610E Emergency Disaster Plan (if there are any changes), Copy of Liability Insurance Certificate and control of property.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. 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: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC809 (FAS) - (06/04)
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