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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804064
Report Date: 09/30/2022
Date Signed: 09/30/2022 03:33:32 PM

Document Has Been Signed on 09/30/2022 03:33 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:ART OF HOMECAREFACILITY NUMBER:
486804064
ADMINISTRATOR:VILLEGAS, IMEEFACILITY TYPE:
740
ADDRESS:1060 FEATHER RIVER CTTELEPHONE:
(707) 372-1355
CITY:VACAVILLESTATE: CAZIP CODE:
95688
CAPACITY: 6CENSUS: 3DATE:
09/30/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Art VillegasTIME COMPLETED:
03:45 PM
NARRATIVE
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 Licensing Program Analyst (LPA) Katrina Walters made an unannounced Post Licensing inspection visit of this licensed senior care facility and met with Licensee, Art Villegas (AV). Administrator Imee Villegas (IV) arrived later.

LPA and AV toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible areas. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerator and freezer were clean, and food was stored properly. Toxins are stored in a locked cabinet in the kitchen. LPA reviewed staff files with IV. There was a supply of paper products and hygiene supplies. Additionally, LPA observed at least a 30 day supply of incontinence products and personal protective equipment.

During the tour at 2:25 PM, LPA observed that staff were using resident (R1)'s closet as a bedroom for staff. (pictures taken). In order to enter the staff room, staff had to pass through resident R1's bedroom and bathroom.

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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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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Document Has Been Signed on 09/30/2022 03:33 PM - It Cannot Be Edited


Created By: Katrina Walters On 09/30/2022 at 03:20 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: ART OF HOMECARE
FACILITY NUMBER: 486804064

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(c)
87307 Personal Accommodations and Services

(C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited when staff used resident R1's bedroom as a passageway to the staff's bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/05/2022
Plan of Correction
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Staff will remove their belongings from the unapproved room. Licensee and Administrator will self-certify that all items have been removed.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2022


LIC809 (FAS) - (06/04)
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