486804064-5-30-2024-21-AS-SMUU-D5RVFV-20240530162430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486804064
Report Date: 05/30/2024
Date Signed: 05/30/2024 04:27:52 PM

Document Has Been Signed on 05/30/2024 04:27 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:	ART OF HOMECARE		FACILITY NUMBER:	486804064
ADMINISTRATOR/ DIRECTOR:	VILLEGAS, IMEE		FACILITY TYPE:	740
ADDRESS:	1060 FEATHER RIVER CT		TELEPHONE:	(707) 372-1355
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY: 6		CENSUS: 6	DATE:	05/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Imee Villegas, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 9:40 AM, Licensing Program Analyst (LPA) Stefanie Mutialu made an unannounced annual required inspection of this licensed senior care facility. LPA was greeted by caregiver, Jocelynn Leano. Administrator, Imee Villegas arrived shortly after at approximately 10:00 AM. The facility is a single story home licensed for six (6) non-ambulatory residents and a hospice waiver capacity of three (3). The facility currently provides care for 6 residents. Four out of six residents were at home, one out of six residents is in the hospital, and one out of six residents was out for a doctors appointment. In addition, there are some residents with a diagnosis of dementia and one patient using oxygen At approximately 10:15 AM, LPA and administrator toured the building and grounds which was found to be clean and in good repair. LPA observed broken and cracked tile on the front walkway. Per Administrator has a quote and has contacted landlord to get repaired. 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 area. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. LPA observed several food items in the refrigerator, freezer, and cabinets that were not properly stored, expired, perishable items not refrigerated, and frozen food that showed signs of freezer burn. Per Administrator most food is staff and will ensure food is properly labeled and stored moving forward. Medication was found in the refrigerator, per Administrator medication refrigerator is broken but is getting repaired today at Best Buy. LPA advised Administrator to get a lock box to store medication in the refrigerator and will need to come up with food storage and labelling system/program. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility does not have back-up water supply for six residents for 72 hours in case of emergency. Administrator advised will pick-up water supply today and provide proof. Toxins are stored in a locked cabinet in the facility laundry room and kitchen. Sharps and other kitchen supplies that could pose danger if available to residents were found secured in the kitchen drawer. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Continued on 809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

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: ART OF HOMECARE	FACILITY NUMBER: 486804064
	VISIT DATE: 05/30/2024

NARRATIVE

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Continued from 809

Water temperature measured within regulation between 108.3 and 113.9 degrees F at two of three faucets accessible to residents. One out of one fire extinguisher was inspected and charged. Five out of five Smoke detectors were present and centralized signal system will lights are present. Carbon Monoxide detector was present, inspected and found to be in working order. There was enough lighting in all common areas, resident rooms, and hallways.

Medications located in designated cabinet were found to be secured. LPA conducted a spot check of medications and found administering and records to be inaccurate. Resident was observed interacting with staff in bedroom and living room. Two of four residents were found in their room. Two of four residents were watching. LPA observed staff checking and caring for residents often. There are puzzles and games along with morning activities such morning exercises, karaoke, and card to keep residents engaged

At approximately 11:00 AM, LPA reviewed Five of Six resident records which were all found to be well organized. One out of six residents files is over due for LIC602 Physicians Report. LPA advised administrator LIC602 is required annually for residents with dementia. Several client records reflected other facility. LPA advised administrator all clients records need to be update to reflect Art of Home facility. At approximately 12:00 PM , LPA reviewed one out of three staff records which were all found to be well organized. staff records missing for two out of three staff. One of three staff records did not contain required annual training for RCFE and Dementia training and First- Aid/CPR/BLS expired as of 03/2024. LPA advised Administrator to provide CCL with a copy of two out of three staff files and proof of completed required training to also include annual Dementia training and current First-Aid certificate. Medication records contained physician's orders for each resident.

Administrator Imee Villegas Administrator Certification 6030808740i current and expires on 06/09/2024.

Continued on 809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

Page: 2 of 13

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: ART OF HOMECARE	FACILITY NUMBER: 486804064
	VISIT DATE: 05/30/2024

NARRATIVE

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Continued from 809C

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

LIC 500 Personnel Summary
LIC 9020 Register of Facility Client’s/Resident's
Staff Training Files/Records
Updated 602s
LIC610E- Disaster Plan (updated with non-local evacuation site)
Evidence of 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.

This report was reviewed with Imee Villegas and Appeal rights were given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:	DATE: 05/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

Page: 3 of 13

Document Has Been Signed on 05/30/2024 04:27 PM - It Cannot Be Edited

Created By: Stefanie Mutialu On 05/30/2024 at 01:07 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: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(a)

General Food Service Requirements

(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
1 2 3 4	Based on observation, LPA observed several food items in the refrigerator, freezer, and cabinets that were not properly stored, expired, perishable items not refrigerated in pots and pan cabinet, decaying vegetables, and open bags of frozen food that showed signs of freezer burn, the licensee did not comply with the section cited above in several food items in two of two refrigerators are not properly stored and expired which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Facility to submit LIC 9098 self certifying all expired, decayed, uncovered, and not properly stored food has been disposed of along with a plan of action to train staff in safe food storage, labelling and handling practices and planned completion date to be submiited to CCL within 24 hours.

Type A

Section Cited

CCR

87465(h)(1)(C)

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview,record review,LPA observed medication in refrigerator accesible to residents, Resident medication records were found to be inaccurate, medication signed for resident for 05/30/2024 however resident is in hospital as of 05/29/2024 @ 11 PM, and PRN controlled substance count did not match medication administering record. Caregiver made an error by presigning for medication for resident that is in the hospital and did not sign for medication (control substance) administered to resident, the licensee did not comply with the section cited above in one out of six resident medication records and one medication bag in unlocked refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2024
	Plan of Correction
1 2 3 4	Facility to submit LIC 9098 self certifying a full audit on stored medication and records has been performed. Facility to provide plan of action for medication retraining for all staff along with planned completion date. Facility to provide this documentation to CCL within 24 hours.

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:

Victoria Bertozzi

LICENSING EVALUATOR NAME:

Stefanie Mutialu

LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

Page: 4 of 13

Document Has Been Signed on 05/30/2024 04:27 PM - It Cannot Be Edited

Created By: Stefanie Mutialu On 05/30/2024 at 02:15 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: 05/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(6)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA observed resident diagnosed with Dementia LIC602 dated from 2022 with no updated appraisal for 2023 and 2024 the licensee did not comply with the section cited above in one out of two reisdents diagnosed with dementia do not have appraisal conducted on an ongoing basis which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2024
	Plan of Correction
1 2 3 4	Facility to submit LIC 9098 self certifying how facility plans to ensure residents diagnosed with dementia have annual appraisal conducted and provide copy of resident's updated LIC602 to be submitted to CCL by 06/06/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Victoria Bertozzi

LICENSING EVALUATOR NAME:

Stefanie Mutialu

LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024

LIC809 (FAS) - (06/04)

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