496804028-4-1-2022-21-AS-CFGS-CD3MRW-20220401095100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804028
Report Date: 03/30/2022
Date Signed: 04/01/2022 09:51:12 AM

Document Has Been Signed on 04/01/2022 09:51 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:	TREEHOUSE SENIOR LIVING		FACILITY NUMBER:	496804028
ADMINISTRATOR:	PATEL, DHARMISTHABEN		FACILITY TYPE:	740
ADDRESS:	1879 ALAN DRIVE		TELEPHONE:	(707) 665-5624
CITY:	PENNGROVE	STATE: CA	ZIP CODE:	94951
CAPACITY: 10		CENSUS: 6	DATE:	03/30/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Dharmi Patel - Licensee/Administrator		TIME COMPLETED:	03:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fernandes-Goes conducted a pre-licensing inspection and met with Licensee/Administrator Dharmi Patel. Fire clearance has been approved for 10 non-ambulatory residents by the County Fire Department. LPA will conduct a component III orientation with Dharmi Patel Administrator/Licensee. There is a total of 6 residents with 3 under Hospice care. Facility is a one-floor facility. LPA toured the facility on 3/30/2022 with Licensee/Administrator Dharmi P.; facility was found to be at a comfortable temperature with all exits free from obstruction. Exits were free from obstructions at the time of the visit. Fire Extinguisher was found to be last charged on 03/2022. Sample test of facility smoke detectors and carbon monoxide detectors were found to be operational. Sample hot water temperature measured 114.8 degrees F falling out Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathroom faucets. The facility has special care plan of operation and programming for residents with dementia. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations. LPA observed that provisions are made for individuals with special dietary needs; facility shares information between staff regarding residents' dietary needs. Food is available for residents any time of the day. There is a daily activity schedule for residents that will be posted after becoming licensed. Toxins are stored in a locked supply room in the hallway. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms inspected designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Mattress pads are available for residents. Continued LIC 809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

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: TREEHOUSE SENIOR LIVING	FACILITY NUMBER: 496804028
	VISIT DATE: 03/30/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility floor includes kitchen, laundry room, living room area, bathrooms, dining room, and resident's bedrooms, and bathrooms, and supply room. Facility plans on having several different activities available for residents as desired and an activity calendar posted by the dining room as well as a menu posted in the kitchen. There is outdoor space for activities. Resident's & Personnel records, medication, first aid supplies, and toxins will be locked in medication closet. Postings noted to be current and in compliance with guidelines. Locked cabinets for sharps and daily used toxins located in office room. PPE is being stored in a supply room.

Disaster Drills have been conducted often and in different shifts with the last one being conducted on 3/1/2022.

Community Care Licensing has requested the following item be corrected prior to licensure:

- Facility to provide pictures of Emergency Preparedness LIC 610, facility sketch approved by Fire Marshall, Non-discrimination and Theft & Loss Facility Program Plan posted as required.
- Facility to provide a copy of Resident R1 complete medical assessment LIC 602.
- Facility to provide a copy of staff S1 fit testing.
- Facility to provide proof of booster shot for staff S1.
- Facility to provide proof of First Aid Kit purchase – facility purchased during visit and showed proof of purchase.

There were no deficiencies cited at this time.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Carla Fernandes-Goes
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4