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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801205
Report Date: 02/14/2024
Date Signed: 02/14/2024 04:52:42 PM

Document Has Been Signed on 02/14/2024 04:52 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:HOEN'S CARE HOMEFACILITY NUMBER:
496801205
ADMINISTRATOR:ALCONES, LILY O.FACILITY TYPE:
740
ADDRESS:1618 MARIPOSA DRIVETELEPHONE:
(707) 573-8922
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 6DATE:
02/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Arthur Alcones, AdministratorTIME COMPLETED:
05:05 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Arthur Alcones arrived later. Facility currently has one resident on hospice which is allowable per the facility's Hospice Waiver.

At approximately 9:30am LPA and Administrator toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. Kitchen cabinet containing cleaning supplies and sharp knives was locked.



Per LPA observation and record review, all bedrooms were equipped with lighting, night stand, and chest of drawers. All bathrooms did not have non-skid bath mats, bathroom in room #5 had a mat but the non-skid did not work and would slide with ease once stepped on(deficiency cited, see 809D). Water temperature in sink(s) accessible to residents in care measured at 118 degrees F which is within the allowable range of 105 to 120 degrees F.

LPA and Admin observed bathroom in room #5 did not have grab bars. Per Title 22 regulation 87303(a)(4) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (4) Grab bars shall be maintained for each toilet; bathtub and shower used by residents (deficiency cited, see 809D). In bathroom #3 the bottom of the sink is cracking and peeling off, a white bath mat was found to have a brown film and was not non-skid. Bathroom in room #1 smelled of urine and brownish yellow pool film of a substance was located on back side of toilet, sticky and yellow film in front of toilet, and spatters of a dark substance on the wall. Also, bathroom in room #5 and room in general had strong smell of urine.

Continued on 809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205
VISIT DATE: 02/14/2024
NARRATIVE
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Continued from 809...

Per Title 22 regulation 87303(a)(1) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition (deficiency cited, see 809D).
Per LPA observation and record review, main hallway bathroom had smears of a dark brown substance in multiple places on the wall and by the toilet paper roll. LPA and Admin also observed darkened wet pieces of wood under peeling wallpaper present on frame at the bottom of the shower. Sink in main bathroom also needs repair as layers upon layers of caulking harboring a brown and orange-yellow substance. LPA and Admin observed bedroom window sills in rooms not free of dirt and debris. LPA and Admin observed front door knob not to work, the door does not latch shut. LPA and Admin observed electrical wall faceplate broken, leaving outlet exposed. Per Title 22 regulation 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors (deficiency cited, see 809D).

At approximately 12:00pm LPA conducted a review of 6 out of 6 resident records. Half rail orders were not on file for R2, R4, and R5. Per Title 22 regulation 87608(a)(5)(A) Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed(deficiency cited, 809D).

Continued on 809C(2)...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205
VISIT DATE: 02/14/2024
NARRATIVE
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Continued from 809C...

Fire extinguishers were last inspected 9/15/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 2/4/2024. Facility has a backup generator for use during a power outage.

Per LPA and Admin observation and record review, residents R4, R5 did not have an admission agreement and R2's admission agreement was not dated by either party. Per Title 22 regulation 87507(a) Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any (deficiency cited, see 809D).

Per LPA and Admiobservation and record review, residents R2 and R3 did not have a current Physician's Report, most current for both dated 2022. Per Title 22 regulation 87705 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 (deficiency cited, see 809D).

At approximately 3:00pm LPA reviewed staff files. S1 did not have Health Screen/TB clearance, CPR/1st aid or complete requirements for training. S1 has been employed since October 2023 so 40 hours is required, only 6 completed. Per Health and Safety Code 1569.625 Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training (deficiency cited, see 809D). A Health Screen for S1 not available. Per LPA interview with S1, they never completed a Helath Screen. Per Title 22 regulation 87412(a)(11) Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411(deficiency cited, see 809D).

Continued on 809C(3)...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205
VISIT DATE: 02/14/2024
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Continued from 809C(2)...

Lily Alcones Administrator Certificate 6013178740 expires 3/9/2024; however, certificate is currently in Renewal-Pending status. All fees are current as of this time.

At approximately 3:50pm LPA and caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet.

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

LIC500- Personnel Report


LIC308- Designation of Responsibility
Evidence of Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. 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: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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Document Has Been Signed on 02/14/2024 04:52 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/14/2024 at 04:09 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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that the main hallway bathroom had smears of a dark brown substance in multiple places on the wall and by the toilet paper roll. LPA and Admin also observed darkened wet pieces of wood under peeling wallpaper present on frame at the bottom of the shower. Sink in main bathroom also needs repair as layers upon layers of caulking harboring a brown and orange-yellow substance. Flaking around the sink in bathroom in room #3. LPA and Admin observed front door knob not to work, the door does not latch shut. LPA and Admin observed electrical wall faceplate broken, leaving outlet exposed. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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2
3
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Admin to submit pictures of all repairs needed for: Main hallway bathroom had smears of a dark brown substance in multiple places on the wall and by the toilet paper roll. Flaking around the sink in bathroom in room #3 repaired. Darkened wet pieces of wood replaced, sink in main bathroom repaired, front door knob working and able to latch, electrical wall faceplate repaired.
Request Denied
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that bathroom in room #1 smelled of urine and brownish yellow pool film of a substance was located on back side of toilet, sticky and yellow film in front of toilet, and spatters of a dark substance on the wall. Also, bathroom in room #5 and room in general had strong smell of urine, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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2
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Admin to submit LIC9098 that all bathrooms are clean and free from urine odor.
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:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


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Document Has Been Signed on 02/14/2024 04:52 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/14/2024 at 04:09 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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in LPA and Admin observed bathroom in room #5 did not have grab bars, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Admin to submit picture of grab bar installed in bathroom #5 by POC due date
Request Denied
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that all bathrooms did not have non-skid bath mats, bathroom in room #5 had a mat but the non-skid did not work and would slide with ease once stepped onwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
1
2
3
4
Admin to submit pictures of non-skid bath mats for each bathroom 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:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 02/14/2024 04:52 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/14/2024 at 04:09 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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S1 Health Screen not available. Per LPA interview with S1, they never completed a Health Screen. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
1
2
3
4
Admin to submit Health Screen with TB clearance by plan of correction due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 02/14/2024 04:52 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/14/2024 at 04:09 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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

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 that S1 did have have all required trainingwhich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
1
2
3
4
Admin to submit all required training for S1 by plan of correction 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:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 02/14/2024 04:52 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/14/2024 at 04:09 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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87507(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R4 and R5 did not have admission agreement and R2's agreement not dated by either party, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2024
Plan of Correction
1
2
3
4
Admin to submit Admin agreements for R4 and R5 as well as dates on R2's admission agreement by plan of correction due date.

Request Denied
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Admin observation, the licensee did not comply with the section cited above in tht doctor order for side rails not present for R2, R4, and R5 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Admin to submit doctor's orders for half rails for R2, R4, and R5 by plan of correction 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:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 02/14/2024 04:52 PM - It Cannot Be Edited


Created By: Christi Coppo On 02/14/2024 at 04:09 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: HOEN'S CARE HOME
FACILITY NUMBER: 496801205

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
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
1
2
3
4
Based on LPa and Admin observation, the licensee did not comply with the section cited above in that R2 and R3 did not have current Physician's report, most recent for both dated 2022 and 2019, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
1
2
3
4
Admin to submit pictures of current Physician's Reports for R2 and R3 by plan of correction due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2024


LIC809 (FAS) - (06/04)
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