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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803853
Report Date: 01/04/2024
Date Signed: 01/04/2024 05:58:54 PM

Document Has Been Signed on 01/04/2024 05:58 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
01/04/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Monicah Gacegu-AdministratorTIME COMPLETED:
06:00 PM
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Licensing Program Analyst(LPA) Alviso conducted a continued annual inspection, at approximately 1:45pm on 1/4/2024, and met with, Administrator Monicah Gacegu. LPA observed two caregivers on duty, Consulata and Pauline.

There are currently five residents in care. The facility is fire cleared for eight (8) non-ambulatory. Hospice waiver is approved for three (3). Facility has a dementia plan of operation. The facility has a required infection control plan. Facility has an emergency disaster plan as required.

LPA reviewed five (5) resident files. All files were complete.
LPA reviewed three (3) staff files, including training. All staff have criminal record clearance as required. All staff have First Aid and CPR certification as required. Staff have required training.

The LPA toured the facility with the caregiver Consulata. The bathrooms were clean, all had grab bars, and mats/non-slip flooring for resident use as needed. There was sufficient lighting in the hallways, resident rooms, bathrooms, and in all common areas. Hot water was checked at 117.4 degrees Fahrenheit. Facility has sufficient food supply, hygiene products, paper products, and cleaners. Sufficient supply of PPE. Sufficient emergency supply to meet 72 hour shelter in place requirements.

Deficiencies observed that will be cited today, see LIC809Ds.
R1's room smelled strongly of urine, and the urine odor can be smelled in the facility's hallway, where R1's room is located. Cited-87625(b)(3) Managed Incontinence) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This is a 2nd citation within 12 months, a civil penalty assessed in the amount of $250-see 421FC

Continued on LIC809C...

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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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Document Has Been Signed on 01/04/2024 05:58 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/04/2024 at 05:03 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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's (observation) R1's bedroom smells strongly of urine odor, and is smelled in the hallway outside resident's bedroom door, 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: 01/12/2024
Plan of Correction
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The Administrator stated that they will make a change in resident's room, cleaning flooring/carpet and/or newer carpet or flooring due to the continued concern of the urine odor. Administrator will submit POC by 1/12/24.
Note: Submit Follow-up by 1/29/24, with completion date of correction, what was done, and maintenance plan on future compliance with this regulation.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/04/2024 05:58 PM - It Cannot Be Edited


Created By: Dina Alviso On 01/04/2024 at 05:14 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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
The following requirements shall apply to medications which are centrally stored: 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations of medication bottle on resident (R1's) night stand. The medication should be centrally stored as required by regulations, the licensee did not comply with the section cited above, which poses an immediate health, safety and/or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Facility to ensure all medications are centrally stored and inaccessible to residents in care; Medications are to be accessible to staff trained to assist residents with medications, per regulation. Centrally store all of R1's medications, and submit how you have completed this, and future plan of compliance. POC due by 1/5/24.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853
VISIT DATE: 01/04/2024
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LPA's observations of medication bottle on resident(R1's) night stand. The medication should be centrally stored as required by regulations. Cited-87465(h)(2) The following requirements shall apply to medications which are centrally stored: 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. This is a 2nd citation within 12 months, a civil penalty assessed in the amount of $250-see 421FC

LPA is requesting the following documents be updated and submitted by 2/4/24:


LIC308 - Designation of Administrator Responsibility
LIC500 - Personnel Report
LIC610E-Emergency Disaster Plan- review and if no changes, submit a copy of last page w/signature & Date. If changes, submit a copy of the plan.
Infection Control Plan-review and if no changes, submit a statement w/signature & Date. If changes, submit a copy of the plan.
Copy of LIC400 Handling of Client Cash Resources, include copy of surety bond if handling cash..
Copy of Current Liability Insurance
Copy of current Administrator Certificate

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 Monicah Gacegu. Appeal rights were provided.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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