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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801091
Report Date: 04/30/2024
Date Signed: 04/30/2024 11:33:19 AM

Document Has Been Signed on 04/30/2024 11:33 AM - 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:HANNA HOUSE SCENICFACILITY NUMBER:
496801091
ADMINISTRATOR/
DIRECTOR:		ADALBERTO OJEDA-MENDEZFACILITY TYPE:
740
ADDRESS:819 SCENICTELEPHONE:
(707) 586-3536
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 6CENSUS: 5DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Adalberto Ojeda (Administrator)TIME VISIT/
INSPECTION COMPLETED:
11:48 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and and was greeted by staff (S1). Administrator Adalberto Ojeda and Licensee David Hanna arrived later.

Upon a review of the Guardian Background Check roster, LPA informed Licensee/Administrator that staff (S1) was fingerprint cleared, but was not associated to facility and should never be working or providing care to residents prior to a criminal record clearance or association was completed. Licensee/Administrator immediately processed documentation to associate S1 to the facility. Civil penalties are being assessed in the amount of $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance exemption.

LPA initiated a tour of the facility at 8:45 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathrooms measured at 113.5, 113.5 and 114.4 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet located in the locked garage containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods. However, LPA had a discussion with Licensee/Administrator about the possibility to buy a variety of fruit for residents. Licensee/Administrator agreed to provide a variety of fruits for residents in care (Technical advisory will be issued). Facility has emergency food and water. Medications were centrally stored and locked.
Continue on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HANNA HOUSE SCENIC
FACILITY NUMBER: 496801091
VISIT DATE: 04/30/2024
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Continued from LIC809...

Fire extinguisher was last inspected July, 2023. Smoke detectors located throughout the facility were tested and operational. Carbon monoxide detector was tested and operational. Exit doors have auditory alert system that were functional at time of visit. Last disaster drill was conducted on April 2, 2024. During visit LPA observed that there were no activities been conducted and had a discussion with Licensee/Administrator regarding the importance of performing activities to promote the development and participation of residents (Technical violation was issued).

LPA initiated file review at 9:15 am. Two staff files and five resident files were reviewed. One out of five resident's (R1) care plan needs to be updated. Staff have required First Aid and CPR certificates. Also, annual required training hours are complete. Administrator Certificate for Administrator Adalberto Ojeda, 6035345740, expires on 5/10/24. Medications and medication records were reviewed. Required postings were observed.

Licensee/Administrator agreed to submit updates of the following documents by 5/10/24: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Emergency Disaster Plan (LIC610E if there are any changes) and a copy of liability insurance.

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 Licensee and a copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/30/2024 11:33 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/30/2024 at 11:09 AM
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: HANNA HOUSE SCENIC
FACILITY NUMBER: 496801091

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff not properly associated with fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Facility immediately processed paperwork to associate S1. Facility to send in self-certification form LIC9098 as proof of correction to CCL by POC due date.
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/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of five residents (R1) needs their care plan to be updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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Licensee to update and complete resident's Needs & Services Plan, with appropriate signatures of Licensee and Resident or resident's responsible party. Facility to submit LIC9098 form ensuring compliance with regulation 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:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
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