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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804055
Report Date: 03/27/2024
Date Signed: 03/27/2024 01:30:03 PM

Document Has Been Signed on 03/27/2024 01:30 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:ALTA CARE HOMEFACILITY NUMBER:
496804055
ADMINISTRATOR:MONTE, AIRA MELANIE V.FACILITY TYPE:
740
ADDRESS:96 ALTA DRIVETELEPHONE:
(707) 508-7634
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 6DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Laarni Lockerbie, Licensee & Aira Melanie Monte, AdministratorTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst’s(LPA’s) Shannan Hansen & Julie Florio arrived unannounced to conduct an Annual Required inspection and met with Licensee, Laarni Lockerbie & Administrator, Aira Monte. There is a total of 6 residents, 1 under hospice care & 2 with diagnosis of dementia.

LPA’s initiated a tour of the facility at approximately 8:45 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. While touring kitchen at approximately 8:50am LPA’s observed cleaning supplies in unlocked cabinet under sink accessible to residents in care (see pic & LIC809-D). Resident’s rooms were furnished per regulation. Water temperature in bathrooms measured at 111.3, 111.7, and 112.1 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Bathrooms used by resident to shower were equipped with necessary grab bars and non-slip floors/mats. While touring bathrooms LPA’s observed with staff (S2) supplements in unlocked drawer and immediately removed by staff(see pics & LIC809-D). Extra hygiene products and linens were available. Cabinet containing cleaning supplies in garage was locked; although upon entering, door to garage was unlocked and alarm was not turned on, LPA’s found razor cutting knife accessible to residents in care and removed by staff (see pics & LIC809-D). There was enough lighting in all common areas, resident rooms, and hallways. Fire extinguisher was last inspected 3/11/2024. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational.

At approximately 9:15 AM, LPA’s reviewed 6 of 6 resident records and found 6 of 6 residents have current physician’s reports and care plans. 6 of 6 resident records contained current and signed admission agreements and physician’s orders on file. Continue on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2024
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 6
Document Has Been Signed on 03/27/2024 01:30 PM - It Cannot Be Edited


Created By: Shannan Hansen On 03/27/2024 at 12:32 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: ALTA CARE HOME
FACILITY NUMBER: 496804055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 4 staff (S1-S4) who do not have health screening and TB test completed as required. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Licensee to have all staff (S1-S4) obtain a health screening and submit copies to Community Care Licensing for review by POC due date 04/10/2024.. Licensee to notify CCL if more time is needed.

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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2024 01:30 PM - It Cannot Be Edited


Created By: Shannan Hansen On 03/27/2024 at 12:32 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: ALTA CARE HOME
FACILITY NUMBER: 496804055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in leaving kitchen cabinet with cleaing supplies & box cutter with razor blade out in garage accessible to resident as the door was unlock to garage, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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 In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Training with staff names ,signatures, & dates to be submitted to CCL by POC due date of 04/10/2024.
Type B
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & interviewr with staff the licensee did not comply with the section cited above in 1 out of 1 bottle of staff supliments were in unlocked bathroom drawer which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Facility to send in written plan they understand regulation and how it will be followed. Facility removed items that should not be accessible and will conduct and send proof of staff training with dates & signatures to CCL by POC due date of 4/10/2024
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:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/27/2024 01:30 PM - It Cannot Be Edited


Created By: Shannan Hansen On 03/27/2024 at 12:32 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: ALTA CARE HOME
FACILITY NUMBER: 496804055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Bases on observation during todays inspection unlocked garage door auditory alarm was not operational and facility has rewsidents with Dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Facility to send in written statement they understand regulation and how they will insure they stay in compliance. facility to send in proof of staff training.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


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: ALTA CARE HOME
FACILITY NUMBER: 496804055
VISIT DATE: 03/27/2024
NARRATIVE
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At approximately 10:20 AM, LPA’s review 5 of 5 staff records. 5 of 5 records contained documentation of completed training as required. Evidence of current first aid and CPR training were observed. 4 out of 5 staff did not have required Health Screening records (see LIC 809-D).

Medications were centrally stored in locked cabinet in the facility living room although second cabinet containing overflow of medications was not locked and accessible to residents in care (see pic & LIC809-D). The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 3/27/2024 at 11:30 AM.



At approximately 12:10 PM, LPA reviewed the facility emergency disaster plan with staff. Facility does not have a generator to supply power during an outage. Administrator informed they are currently deciding how to handle emergency outages with residents on oxygen and other. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducts disaster drills quarterly and documented last disaster drill on 2/23/2024. Administrator Certification for Aira Melanie U Monte 6056005740 expires 08/29/2024. LPA reviewed Licensing Information System (LIS) with Licensee who stated that is correct and updated at this time; no need to change any of the information.

Appeal Rights Given.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 4/10/2024:

LIC 308 Designation of Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if changes)
LIC 9020 Register of Facility Client’s/Resident’s
Proof of Liability Insurance
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/27/2024 01:30 PM - It Cannot Be Edited


Created By: Shannan Hansen On 03/27/2024 at 01:01 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: ALTA CARE HOME
FACILITY NUMBER: 496804055

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465 Incidental Medical and Dental Care

(h) The following requirements shall apply to medications which are centrally stored:
(2) 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 observation, the licensee did not comply with the section cited above by 1 of 1 medication storage cabinets was not locked and inaccessable to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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Licensee agrees to submit self certification stating that the medication cabinets will remain locked when staff are not actively utilizing the medications by POC due date of 3/28/2024 & in-service training to be provided to all staff who handle medications and submit signed/dated certificate to CCL by 2nd POC due date of 4/10/2024.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024


LIC809 (FAS) - (06/04)
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