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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803853
Report Date: 12/23/2021
Date Signed: 12/23/2021 05:38:53 PM

Document Has Been Signed on 12/23/2021 05:38 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:MOGRACE RESIDENCEFACILITY NUMBER:
496803853
ADMINISTRATOR:GACEGU, MONICAHFACILITY TYPE:
740
ADDRESS:6299 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7884
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 8CENSUS: 5DATE:
12/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Monicah Gacegu-AdministratorTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA), Dina Alviso, arrived unannounced to conduct a Required- 1 Year inspection, and met with a caregiver on duty, Susan Nyambura. Licensee/Administrator Monicah Gacegu arrived to the facility after the caregiver contacted her to notify her of the LPA's arrival. The inspection will focus on the Infection Control procedures and practices of this facility.

LPA checked employee fingerprint clearances, and observed that Susan Nyambura was not on the list of associated staff for Mograce Residence; LPA also checked the Guardian Fingerprint Database, and there was no fingerprint information found on a "Susan Nyambura". The Licensee questioned Susan Nyambura on when, and if, she had fingerprinted. LPA discussed regulation 87355 Criminal Record Clearance with the Monicah, Licensee/Administrator. The LPA discussed with the Licensee/Administrators responsibility to ensure compliance with this regulation in hiring staff, and ensuring all staff have DOJ clearance as required before coming into the facility , and working in the facility. The violation will be cited today, Criminal Record Clearance 87355 (e)(1)-see LIC809D. An immediate Civil Penalty will be assessed today, in the amount of $500.- see LIC421BG. Susan Nyambura left the facility immediately; Licensee understands that Susan Nyambura is not to return to work or be on facility premises until obtaining a criminal record clearance and/or criminal record clearance exemption.

Facility has an approved dementia plan of operation. There is an approved hospice waiver for three (3) residents. Mitigation plan was reviewed by the Department on 3/16/21. Fire clearance is approved for eight(8) non-ambulatory residents.-effective 8/9/2019.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853
VISIT DATE: 12/23/2021
NARRATIVE
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There were 5 residents in care at the facility during this inspection. One resident is on Hospice Care Services. Per Licensee, four(4) staff are fully vaccinated, and Boosters are scheduled. All visitors, essential visitors, and staff are screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened twice daily, and observed for any changes, all information is logged. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. Administrator stated that staff wear masks in the facility, and also when providing care services to the residents in and out of the facility. Administrator had a mask on during the LPA's inspection.

The following deficiency was observed (see LIC 809D) and 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 and appeal of rights provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/23/2021 05:38 PM - It Cannot Be Edited


Created By: Dina Alviso On 12/23/2021 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
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2021
Section Cited

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Criminal Record Clearance- 87355(e)(1)- All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a
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California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by LPA's review of staff associations list from Departments LIS Data Base, and review of DOJ Fingerprint Lists/Clearance Information in the Guardian website.Licensee stated to the LPA that she did not follow-up on Susan Nyambura's fingerprinting documentation and/or ensure she had fingerprint clearance. This is a personal rights/Health and Safety violation and risk to all residents in care. An immediate Civil Penalty will be assessed in the amount of $500-see LIC421BG.
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Licensee/Administrator stated her understanding of the regulation and information stated above. Licensee to submit facility policy and procedures regarding hiring staff and fingerprint clearance requirements, and plan in ensuring compliance with the regulation. POC due 12/24/21.

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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 12/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2021


LIC809 (FAS) - (06/04)
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