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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803731
Report Date: 08/16/2021
Date Signed: 08/16/2021 01:35:25 PM

Document Has Been Signed on 08/16/2021 01:35 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LAS PALMAS ASSISTED LIVINGFACILITY NUMBER:
496803731
ADMINISTRATOR:PRICE, THOMASFACILITY TYPE:
740
ADDRESS:218 N HIGH STREETTELEPHONE:
(707) 583-5895
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 5DATE:
08/16/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Josephine Blancaflor (Licensee)TIME COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management- Legal/Non-compliance inspection and met with Licensee, Josephine Blancaflor. This inspection is being completed to ensure compliance with Non-Compliance Conference dated 9/4/2019. LPA conducted a Risk Assessment call with Licensee prior to the visit.

CCR 87303 (e)(2) - Maintenance & Operation - Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. LPA/Licensee observed hot water temperature on 107.6, 107.2 and 107.2 degrees F within regulation of 105 to 120 degrees F in 3 of 3 resident’s bathrooms.

CCR 97555 (b)(9) - unlabeled/expired food. General Food Service Requirements - Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. Food stored in the kitchen refrigerator were properly stored and labeled as per regulations.

CCR 87465(c)(2) - Incidental Medical and Dental Care - If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...facility staff designated by the licensee shall be permitted to assist the resident. Medications and medication records were reviewed.

CCR 87705 (f)(1) unsecured tools accessible - The following shall be stored inaccessible to residents with dementia: (1) tools and other items that could constitute a danger to the resident(s). LPA/Licensee observed dangerous items are stored inaccessible to residents with dementia.

This case management-legal/non-compliance inspection is complete.

No citations issued during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2021
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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