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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496801807
Report Date: 05/13/2022
Date Signed: 05/13/2022 03:24:12 PM

Document Has Been Signed on 05/13/2022 03:24 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:YERBA BUENA RESIDENTIAL CARE HOMEFACILITY NUMBER:
496801807
ADMINISTRATOR:MARTINEZ, ANGELICAFACILITY TYPE:
740
ADDRESS:5200 YERBA BUENATELEPHONE:
(707) 539-6780
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 6CENSUS: 6DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee/Administrator, Angelica MartinezTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required-1 Year inspection at approximately 1:00 PM, and was initially greeted by staff. Licensee/Administrator, Angelica Martinez arrived shortly The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was asked fill out a screening form and sign in. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff completed Personal Protective Equipment (PPE) and infection control training last year through Kaiser. High touch surface areas are disinfected daily. Due to residents having private rooms they could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. Licensee plans to fit test staff after undergoing training.

Residents' emergency contact information has been updated and staff indicated they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet and in locked cabinets under the kitchen and bathroom sinks. A 30 day supply of medications are locked in administrator's office. The facility has a sufficient supply of PPE located in garage. All exit alarms on exit doors were working properly. Facility is not currently conducting surveillance testing. All staff have received their booster shot and all residents have received their booster shot.

Continued on LIC 809C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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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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: YERBA BUENA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496801807
VISIT DATE: 05/13/2022
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During tour of the facility LPA observed two half rails placed together that ran the full length of a resident's bed. Interview with administrator revealed resident is not receiving hospice services. Administrator provided discharge paperwork indicating the need for bed rails. Paperwork does not specify half or full bed rails.

LPA requested the following updated documents:

LIC 500
LIC 9020
Emergency Disaster Plan
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 administrator and a copy of this report printed for the facility.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/13/2022 03:24 PM - It Cannot Be Edited


Created By: Erik Gonzalez Campos On 05/13/2022 at 02:31 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: YERBA BUENA RESIDENTIAL CARE HOME
FACILITY NUMBER: 496801807

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 6 resident bedrooms. Resident bed had two half rails placed together running the full length of the bed which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/13/2022
Plan of Correction
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Licensee removed one half rail during inspection. Deficiency cleared during inspection on 05/13/2022
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:Kimberley Mota
LICENSING EVALUATOR NAME:Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
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