Community Care Licensing

Document Has Been Signed on 02/18/2025 11:06 AM - It Cannot Be Edited

FACILITY NAME:	SLEEPY HOLLOW ASSISTED LIVING		FACILITY NUMBER:	496803576
ADMINISTRATOR/ DIRECTOR:	ARTHUR ALCONES		FACILITY TYPE:	740
ADDRESS:	3707 SLEEPY HOLLOW DRIVE		TELEPHONE:	(707) 953-2161
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY: 6		CENSUS: 6	DATE:	02/18/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:09 AM
MET WITH:	Arthur Alcones-Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

SUPERVISORS NAME: Bethany Moellers LICENSING EVALUATOR NAME: Dina Alviso LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025

Link to Parent Document Below:

FACILITY NAME: SLEEPY HOLLOW ASSISTED LIVING	FACILITY NUMBER: 496803576
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/18/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/19/2025 Section Cited CCR 87465(h)(1)(C)(2)	1 2 3 4 5 6 7	87465(h)(1)(C )(2) Incidental Medical and Dental Care- 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,Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.	1 2 3 4 5 6 7	Licensee to ensure that all medications are centrally stored and inaccessible to residents in care. Hold an in--service medication training with all staff. Submit plan of correction by 2/19/25. Submit proof of training by 2/28/25.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPAs observed numerous over-the-counter medications on R2's side bed table in their room. Resident's medications are provided by staff assistance. Resident does not centrally store and/or handle own medications, per interviews. This is a health & Safety risk to residents in care. LPA obtained photos.	8 9 10 11 12 13 14
Type A 02/19/2025 Section Cited CCR87309(a)	1 2 3 4 5 6 7	87309(a)Storage Space and Access-Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.	1 2 3 4 5 6 7	Licensee to ensure the bathroom that is under renovation is kept locked and inaccessible to all residents in care at all times. Once the bathroom renovation is complete, it may be open to sue by residents in care. Submit plan of renovation estimated completion date, and plan of securing the bathroom, ensuring it is inaccessible. POC due 2/19/25.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: LPAs observed a facility bathroom that is under renovations unlocked, making tools stored in the bathroom accessible to residents in care, and observed trip hazards, a lip of some tile fitted on the floor, and the hole in the floor where the toilet was removed. There is no door knob lock on the bathroom door leaving all accessible to residents in care. This is a health & safety risk to the residents in care. LPA obtained photos.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Dina Alviso LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025