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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803924
Report Date: 10/19/2023
Date Signed: 10/19/2023 04:53:03 PM

Document Has Been Signed on 10/19/2023 04:53 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:SONOMAMODELXFACILITY NUMBER:
496803924
ADMINISTRATOR:ALEXANDER VARSHAVSKYFACILITY TYPE:
740
ADDRESS:765 DONALD STREETTELEPHONE:
(415) 264-5486
CITY:SONOMASTATE: CAZIP CODE:
95476
CAPACITY: 32CENSUS: 23DATE:
10/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator Alex VarshavskyTIME COMPLETED:
05:07 PM
NARRATIVE
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Licensing Program Analysts Cuadra and Coppo arrived unannounced to conduct an Annual Required Inspection and met with Licensee/Administrator, Alex Varshavsky. Licensee/owner Julia Latifi arrived later. Facility currently has Hospice Waiver for 10 residents including 2 bedridden residents allowed.

LPAs/Administrator initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature. Passageways were free from obstructions. Not all resident rooms were furnished per Title 22 regulation 87307(3)(B): room numbers 2,3,4,and 9 all were missing a lamp for each resident, Technical Advisory given. Water temperature in sink accessible to residents in care measured at 102.2 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars.Facility has at least two days of perishable and seven days of non-perishable foods. Required postings were observed.

At approximate 9:15am LPAs/Administrator observed 4 out 5 fire extinguishers were last inspected 09/28/2022 which is out of compliance per Title 22 regulation 87202(a). Smoke alarms/Carbon Monoxide detectors were tested and operational per fire inspection tag serviced on 02/10/2023. Last fire drill conducted 09/14/2023.

At approximately 10:00am LPAs/Administrator started file review of five staff files and ten resident files. 10 out of 10 residents' Care Plans were not signed by a responsible party as required per Title 22 regulation 87463(c). R10 did not have a care plan and their admission agreement was not signed by their responsible party. Also, residents (R7 and R9) who have a diagnosis of dementia, did not have a current medical assessments within the last 12 months as required per regulation. LPAs discussed with Administrator the importance of having care plans, medical assessments, and admission agreements signed. Administrator agreed to update residents' files to be in compliance with Title 22 regulations to avoid further citations. Continued on LIC809C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: SONOMAMODELX
FACILITY NUMBER: 496803924
VISIT DATE: 10/19/2023
NARRATIVE
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continued from 809..

At approximately 12:30pm LPAs/Licensee found that 5 out of 5 staff members did not have their training records. The records were not maintained or updated. 3 out of 5 staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Alexander Varshavsky 6052513740 expires 07/03/2023 (pending). LPAs/Licensee had a discussion about staff training record requirements and Licensee agreed to review and update staff records as well as implement organizational system.

At approximately 1:30pm LPAs/Administrator conducted a spot check of medications and observed residents' (R2, R11, R12, R13 & R14) medications are been crushed. However, LPAs were informed by Licensee that there are no physician's crush orders on file to crush medications for residents as required per regulation 87465 (a)(5)(D). Also, Centrally stored medication records have not been maintained current as required by 87465 (a)(6). Based on record review, the facility has not contacted a pharmacy to review their medication management at least twice per year as required by regulation H&S 1569.69 (g).

At approximately 2:00pm LPAs/Administrator observed facility's resident alert signal does not produce auditory signal loud enough to alert staff when residents need assistance as required per regulation 87303 (i)(1)(B).



Administrator provided LPAs a copy of their liability insurance and a copy of current lease.

Licensee/Administrator to submit updates of the following documents by 11/02//2023:



LIC 308 Designation of Responsibility forms.
LIC 500 Personnel Summary


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/owner and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 10/19/2023 04:53 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/19/2023 at 03:15 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: SONOMAMODELX
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on LPA/Licensee observation, the licensee did not comply with the section cited above in [4] out of [5] fireextinguishers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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2
3
4
Licensee to submit photos of serviced fire extinguishers showing current service date by POC due date.
Type A
Section Cited
CCR
87465(a)(5)(D)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPAs interview with licensee, the licensee did not comply with the section cited above in 5 count out of 5 residents did not have a physician's crush order on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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3
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Licensee agrees to provide a written procedure of how the facility's staff will ensure compliance with Title 22 regulations by POC due date. Licensee will obtain physician orders for crushing medications as proof that all medications being crushed are in adherance to physicians' orders.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 10/19/2023 04:53 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/19/2023 at 03:15 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: SONOMAMODELX
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(h)
Maintenance and Operation
(h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPAs and licensee's observation, the licensee did not comply with the section cited above in resident's bedrooms did not have emergency lighting while electric contractor was working on replacing fuse boxes of electrical system, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee agreed to put battery operated lights in resident's rooms to ensure proper lighting during power outages or when electrical work is been performed. Licensee will submit a picture as a proof of compliance by POC due date.
Type B
Section Cited
CCR
87303(i)(1)(B)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and interviews with licensee, the licensee did not comply with the section cited above in facility's resident alert signal did not produce auditory signal to alert staff when residents need assistance, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee agreed to submit a written procedure about how the facility will ensure compliance with Title 22 regulations by POC due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 10/19/2023 04:53 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/19/2023 at 03:15 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: SONOMAMODELX
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's observation, records review and interview with the licensee, the licensee did not comply with the section cited above in 10 out of 10 resident's care plans have not been signed by the resident/responsible party within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee agrees to submit proof that resident/responsible party had been contacted to acknowledge and sign residents' care plans. Licensee will reach out to responsible parties by email or certified mail as proof of licensee's effort to obtain signatures.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, records review and interview with Licensee, the licensee did not comply with the section cited above in 1 out of 10 resident (R10) who has a diagnosis of dementia signed their own admissions agreement, without a responsible party acknowledging of the contents of the document, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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Licensee agreed to submit proof that responsible party acknowledged the contents of the admission agreement by POC due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 10/19/2023 04:53 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/19/2023 at 03:15 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: SONOMAMODELX
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPAs observation, records review and interview with licensee, the licensee did not comply with the section cited above in 5 out of 5 staff members did not have their training records maintained or updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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3
4
Licensee agreed to review and submit proof of staff required training hours to CCL by POC due date to clear the citation.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA's observation, records review and interview with the licensee, the licensee did not comply with the section cited above by not maintaining Centrally Stored Medication Records current for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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3
4
Licensee agreed to submit photos of corrected pages as proof that the facility medication technicians have reviewed, input and corrected medication logs by POC due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 10/19/2023 04:53 PM - It Cannot Be Edited


Created By: Christi Coppo On 10/19/2023 at 03:15 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: SONOMAMODELX
FACILITY NUMBER: 496803924

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(g)
Other Provisions
(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, records review and interview with licensee, the licensee did not comply with the section cited above, facility has not contacted a pharmacy to review their medication management at least twice per year as required by regulation, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
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2
3
4
Licensee will contact a pharmacy to come and review their medication management and will submit proof of pharmacy audit as indicated by regulation.
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's observation, records review and interview with Licensee, the licensee did not comply with the section cited above in 2 out of 10 residents (R7 and R9) who have a dementia diagnosis, but their medical assessments have not been updated since 2021, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2023
Plan of Correction
1
2
3
4
Licensee agreed to obtain current medical assessments for residents and will submit current LIC602 physician's report to CCL by POC due date.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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