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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803731
Report Date: 05/29/2024
Date Signed: 05/29/2024 11:39:09 AM

Document Has Been Signed on 05/29/2024 11:39 AM - 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:LAS PALMAS ASSISTED LIVINGFACILITY NUMBER:
496803731
ADMINISTRATOR/
DIRECTOR:		ERNESTO IDANGFACILITY TYPE:
740
ADDRESS:218 N HIGH STREETTELEPHONE:
(707) 583-5895
CITY:SEBASTOPOLSTATE: CAZIP CODE:
95472
CAPACITY: 6CENSUS: 6DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:44 AM
MET WITH:Josephine Blancaflor (Licensee)TIME VISIT/
INSPECTION COMPLETED:
11:53 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Administrator, Ernesto B Idang. Licensee, Josephine Blancaflor arrived later. Fees are current. Contact information was reviewed. There are residents with a diagnosis of dementia.
LPA/Administrator initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 109.2 & 110.3 degrees F which was within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Kitchen cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Fire extinguisher was last inspected April 2024. Facility has hardwired combination smoke/carbon monoxide detectors located throughout the facility that were tested and operational. Exit doors have auditory alert system that were functional at time of visit. Last disaster drill was conducted on April 3, 2024.

At approximate 9:15am LPA/Administrator observed facility kitchen to have a baby fence with a lock on the door that it was unlocked during the inspection. Per Administrator, the facility locks the door for the safety of residents with dementia who may try to eat "food" at night. Also, the refrigerator located in the hallway was observed with a chain around it to keep residents away from accessing the refrigerator. LPA had a conversation with Administrator/Licensee, they removed the fence, chain and locks from the kitchen area. Licensee agreed to not lock the kitchen without an approved waiver from the Department. A technical violation will be issued. Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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: LAS PALMAS ASSISTED LIVING
FACILITY NUMBER: 496803731
VISIT DATE: 05/29/2024
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Continued from LIC809...

File review was initiated at 9:30am. Three staff files and six resident files were reviewed. Staff have required First Aid and CPR certificates. Training records reviewed. Residents have current medical assessments and care plans updated within the last 12 months. Administrator Certificate for Administrator, Ernesto B Idang expires 4/15/2025. Medications and medication records were reviewed. Required postings were observed.

Licensee/Administrator to submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), lease agreement and copy of 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 Licensee and a copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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