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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803576
Report Date: 12/06/2024
Date Signed: 12/06/2024 04:46:41 PM

Document Has Been Signed on 12/06/2024 04:46 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:SLEEPY HOLLOW ASSISTED LIVINGFACILITY NUMBER:
496803576
ADMINISTRATOR/
DIRECTOR:		ARTHUR ALCONESFACILITY TYPE:
740
ADDRESS:3707 SLEEPY HOLLOW DRIVETELEPHONE:
(707) 953-2161
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 5DATE:
12/06/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Arthur Alcones-AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analysts (LPAs) Alviso and Stevenson arrived unannounced to conduct a continued annual inspection, on 12/6/24 at approximately 11:05am, and was greeted by staff. Staff contacted Licensee/Administrator Arthur Alcones to notify them of the LPAs arrival. Administrator Arthur arrived to meet with the LPAs.

Fire clearance approval for six (6) non-ambulatory, of which one (1) may be bedridden. The facility has a required infection control plan. The facility has a required emergency disaster plan as required. Facility has an approved dementia plan.

The LPA toured the facility with staff. Hot water was measured at 120. degrees Fahrenheit, which is within regulation. Administrator will continue to ensure the hot water is within regulation, and not above 120.degrees and/or below 105 degrees Fahrenheit. There are three full bathrooms, and one 1/2/bathroom for residents use, but one of the full bathrooms is being renovated and is inaccessible at this time. Administrator to ensure the bathroom remains inaccessible to residents in care until renovation is complete. Administrator stated their understanding of the above. Bathrooms had grab bars and showers floor mats for resident use. The facility had sufficient lighting in all common areas, resident rooms, bathrooms, and hallways. Food supply was sufficient. All smoke alarms were working properly during the inspection; The facilities carbon monoxide detector was working properly during the inspection. Fire extinguisher, one (1), was being serviced and tagged during the inspection. Medications are kept in a small medication room that has a lock to keep medications locked and inaccessible to residents in care.

LPAs reviewed five (5) resident files, including medication records. The LPAs reviewed four (4) staff files, including training. All staff had criminal record clearance as required. All staff had cpr and first aid certification as required.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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: SLEEPY HOLLOW ASSISTED LIVING
FACILITY NUMBER: 496803576
VISIT DATE: 12/06/2024
NARRATIVE
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LPA is requesting the following documents be updated and submitted by 1/6/25:
LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan (ensure to review and update as needed/required)
Infection Control Plan (ensure to review and update as needed/required)
Copy of LIC400 Handling of Client Cash Resources (include copy of surety bond if handling cash)
Copy of Current Liability Insurance
Resident Roster
Copy of current Administrator Certificate.
The following deficiencies were observed during the inspection and will be cited:

LPAs' observed the staff room on the first floor unlocked, which had cigarettes, matches, and over the counter medications left accessible to residents in care. LPAs observed second floor staff room unlocked, which had numerous bottles of alcohol and disinfectants/cleaners left accessible to residents in care. This deficiency will be cited, 87705(f)(1)(2) Care of Persons with Dementia-The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants, see LIC809D.

LPAs observed a hallway entry with the floor’s wooden transition strip with a large chunk missing which has created a health & safety hazard for potential to trip and/or fall.LPAs observed an outlet in a resident room is missing 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, see LIC809D.

LPAs observed a resident’s room (R4’s) smells of urine odor; R4 is incontinent per review of records. This deficiency will be cited, 87625(b)(3) Managed Incontinence- In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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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: SLEEPY HOLLOW ASSISTED LIVING
FACILITY NUMBER: 496803576
VISIT DATE: 12/06/2024
NARRATIVE
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LPAs observed that the facility lacked an adequate emergency food supply as required by the health and safety code. This deficiency will be cited, 1569.695(a)(2) (a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage, see LIC809D.

LPAs observed that the facility having complaint poster posted per regulation which poses/posed a potential health, safety or personal rights risk to persons in care.87468(c)(2)(A) Personal Rights- Licensees shall prominently post personal rights, nondiscrimination notice, & complaint information in areas accessible to residents, representatives, & the public. Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the RCFE Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website, see LIC809D.


Deficiencies 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 with Administrator/Licensee Arthur Alcones.
Appeal Rights provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 04:46 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/06/2024 at 03:29 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: SLEEPY HOLLOW ASSISTED LIVING
FACILITY NUMBER: 496803576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)(2)
87705(f)(1)(2) Care of Persons with Dementia-The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs' observed the staff room on the first floor unlocked, which had cigarettes, matches, and over the counter medications left accessible to residents in care. LPAs observed second floor staff room unlocked, which had numerous bottles of alcohol and disinfectants/cleaners left accessible to residents in care, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2024
Plan of Correction
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Licensee/Administrator to ensure that staff rooms remain locked and inaccessible to residents in care and/or remove all items listed above to ensure residents have no access to the items listed above found in both staff rooms. Staff locked the room on the first floor, and Administrator to ensure the door leading to the second floor staff room is locked and inaccessible to residents in care. Submit plan of correction by 12/7/24.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/06/2024 04:46 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/06/2024 at 03:36 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: SLEEPY HOLLOW ASSISTED LIVING
FACILITY NUMBER: 496803576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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
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LPAs observed a hallway entry with the floor’s wooden transition strip with a large chunk missing which has created a health & safety hazard for potential to trip and/or fall, an outlet in a resident room is missing, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee/Administrator to ensure that the floor's transition strip is repaired and/or replaced as needed for the safety of residents, staff and others who are in the facility. Licensee to ensure the outlet cover is replaced in residents room. Submit photo of outlet cover having been replaced. Submit photos of the repaired and/or replaced transition strip, with written self confirmation of having completed the correction. POC due 12/09/24.
Type B
Section Cited
CCR
1569.695(a)(2)
1569.695(a)(2) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed that the facility lacked an adequate emergency food supply as required by the health and safety code, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Licensee agrees to obtain needed emergency food supplies per requirements by H&S code; Please submit a list and picture(s) of supplies no later than POC due date, 12/13/24.
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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 12/06/2024 04:46 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/06/2024 at 04:11 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: SLEEPY HOLLOW ASSISTED LIVING
FACILITY NUMBER: 496803576

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A
87468(c)(2)(A- Personal Rights- Licensees shall prominently post personal rights, nondiscrimination notice, & complaint information in areas accessible to residents, representatives, & the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the RCFE Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPAs observed that the facility had no complaint poster up and visible per regulation requirement, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/13/2024
Plan of Correction
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Licensee agrees to post the CCL Complaint Poster per regulation; Submit a picture showing the poster is in the main entryway no later than POC due date, 12/13/24.

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:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2024


LIC809 (FAS) - (06/04)
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