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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803996
Report Date: 12/20/2024
Date Signed: 12/20/2024 06:37:51 PM

Document Has Been Signed on 12/20/2024 06:37 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:AGING IN THE BAY 2FACILITY NUMBER:
486803996
ADMINISTRATOR/
DIRECTOR:		MENDAROS, CHARMAINEFACILITY TYPE:
740
ADDRESS:1325 POTRERO CIRCLETELEPHONE:
(510) 388-7352
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY: 6CENSUS: 6DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Charmaine Mendaros, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:50 PM
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At approximately 10:30 AM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection and were greeted by Mary Ann Ordono, Caregiver/Designated Responsible Party (DPR). Charmaine Mendaros, Administrator was contacted via telephone, gave LPAs permission to begin inspection with DRP, and Administrator arrived approximately one (1) hour later at 11:30 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. All residents were present during today's inspection. Facility has a hospice waiver for five (5), a bedridden waiver for one (1), is approved for all non-ambulatory residents, and currently has three (3) hospice residents in care.

At approximately 10:50 AM, LPAs initiated a tour of the facility with DRP and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. LPAs observed a lock installed near the top of the front door of the facility and advised Administrator to ensure that all facility exterior doors remain in compliance with regulation for a facility not approved for a secured perimeter unless otherwise approved by The Department, (see LIC809D). Administrator removed the lock immediately. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens and hygiene, paper and incontinent care products available to residents. Residents' bedrooms were inspected and observed to have the appropriate furnishings as outlined in Title 22 regulations. LPAs observed mouse droppings in the food pantry and an activated mouse trap in resident bedroom 3, (see LIC809D). Cabinets containing cleaning supplies and other items that could pose a risk were locked. However, LPAs observed the key used to unlock said cabinets hanging on a hook in the kitchen where accessible to residents in care, (see LIC809D). Facility has at least two days of perishable food and an emergency water supply.

Continued on LIC809-C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996
VISIT DATE: 12/20/2024
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Continued from LIC809C...

LPAs advised administrator to increase the amount of non-perishable food/emergency food to ensure facility has at least a one week supply. Additionally, LPAs observed several perishable food items transferred into storage containers that were not labeled with the item name, expiration date, or open date, (see LIC809D). Medications were centrally stored and locked. There is a covered seating area in the backyard with outdoor space for activities. LPAs observed a missing screen door and at least two window screens in disrepair, (see LIC809D). LPAs observed an activity schedule and games, puzzles, and activities for residents in care. Facility hosted their holiday party last night for residents in care. Administrator agreed to purchase an additional internet access device which will be dedicated for resident use and facility has internet service available to residents in care. The facility telephone was tested an operational during inspection.

Facility's fire extinguisher was observed charged and was last serviced February 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 10/2024. LPAs observed the facility's infection control plan, first aid kit, PPE, and other emergency supplies. LPAs reviewed facility's emergency disaster plan last updated 11/2021.

At approximately 12:30 PM, LPAs reviewed five (5) staff files which all contained the required paperwork including the required CPR and First Aid training certificates. However, Staff 1 (S1) and Staff 2 (S2) were deficient in proof of completed initial training hours, (see LIC809D). LPAs conducted file review of all six (6) resident files and observed two (2) or more of the required documents either missing or not signed and dated from each file, (see LIC809D). LPAs advised Licensee to ensure all documents are complete, signed, and dated.

At approximately 3:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. However, LPAs observed expired medications, (see LIC809D). Licensee states facility coordinate sresidents' medical and dental appointments and coordinates their transportation to and from visits with residents' family or a third party transportation service. Facility does not manage cash resources for residents.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
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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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996
VISIT DATE: 12/20/2024
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Continued from LIC809C...

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • LIC610 Emergency Disaster Plan (updated)
  • LIC500 Personnel Report (updated)
  • Proof of Current Liability Insurance


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 12/20/2024 06:37 PM - It Cannot Be Edited


Created By: Julie Florio On 12/20/2024 at 05:20 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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

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 ensuring the facility window screen are in place and in good repair, and that the facility is free from rodents as evidenced by a mouse trap set in bedroom number 3 and mouse droppings observed in the facility pantry which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
1
2
3
4
Licensee to submit a self certification to CCL that they will ensure facility window screens are in place and in good repair and that the facility is free from rodents to CCL by POC due date 12/23/2024.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on observation, the licensee did not comply with the section cited above in ensuring that keys used to unlock cabinets containing item which could pose a risk to residents in care remains inaccessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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3
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Licensee to submit a self certification to CCL that they will ensure that keys for cabinets containing item which could pose a risk to rodents in care remain inaccessible to residents in care to CCL by POC due date 12/23/2024.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 12/20/2024 06:37 PM - It Cannot Be Edited


Created By: Julie Florio On 12/20/2024 at 05:20 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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

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 ensuring that centrally stored medication records were maintained accurately and that expired medications were removed from residents' stored medications which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
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Licensee to submit proof of training completed by all staff regarding the proper maintenance of centrally stored medication records to CCL by POC due date of 1/20/2025.
Type B
Section Cited
CCR
87506(a)
Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above where LPAs observed at least two documents missing or not signed and dated for each resident in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
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Licensee to submit Self certification to CCL that all resident records are current and complete with signature and date to CCL by POC due date 1/20/2025.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 12/20/2024 06:37 PM - It Cannot Be Edited


Created By: Julie Florio On 12/20/2024 at 05:44 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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(l)(1)
Care of Persons with Dementia
87705(l)(1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates.

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 the observed instance of a lock that was installed at the top of the facility's front door which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Licensee immediately uninstalled the lock from the door. POC cleared during inspection.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 12/20/2024 06:37 PM - It Cannot Be Edited


Created By: Julie Florio On 12/20/2024 at 05:49 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: AGING IN THE BAY 2
FACILITY NUMBER: 486803996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)

General Food Service Requirements
87555(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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 ensuring that all food in properly labeled when transferred to new storage containers/packaging which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
1
2
3
4
Licensee to submit self-certification that all food has been inspected and in labelled and stored in compliance with regulation to CCL by POC due date 1/20/2025.
Type B
Section Cited
CCR
87411(c)

Personnel Requirements – General 87411(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69

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 where S1 and S2 were observed missing proof of 10 or more hours of initial training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
1
2
3
4
Licensee to submit proof of completed initial training hours for S1 and S2 to CCL by POC due date 1/20/2025.
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:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024


LIC809 (FAS) - (06/04)
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