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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804107
Report Date: 11/02/2023
Date Signed: 11/02/2023 12:33:13 PM

Document Has Been Signed on 11/02/2023 12:33 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:NIGHTINGALE CARE HOMES LLCFACILITY NUMBER:
496804107
ADMINISTRATOR:BOTONES, ANNA KARINAFACILITY TYPE:
740
ADDRESS:5161 OAK MEADOW DRIVETELEPHONE:
(415) 341-7649
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 6CENSUS: 5DATE:
11/02/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Cassie Guerrero (Lead Staff)TIME COMPLETED:
12:47 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted the Post Licensing inspection and met with lead staff Cassie Guerrero designated substitute on file. Licensee/Administrator was not able to come to the facility due to their residency is a distance away from the facility, which it was previously discussed with Licensee during pre-licensing visit conducted on 12/15/22. LPA have a discussion via phone with Licensee and was informed their intentions are to appoint an Administrator that will ensure to spend a reasonable amount of time in the facility, resident's care needs will be met in case of an emergency and Community Care Licensing inspections. Documents needed to appoint a new Administrator are as follow: (LIC 500) Personnel Report, LIC308 Designation of Facility Responsibility, LIC215 Applicant Information, LIC501 CCL/Personnel Record and detailed employment/education history. Facility has a Dementia Care Plan approved to care for residents with dementia care needs. No residents in hospice.
Facility is a single story residence and has 5 bedrooms for residents in care. The fire clearance for six non-ambulatory residents was granted 11/1/2022 by Sonoma County Fire Department. Fire extinguisher was last serviced 12/13/2022. The facility have not conducted a fire drill for the last quarter. LPA/Staff initiated a tour of the facility at 9:00 am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Smoke alarms and carbon monoxide detector were tested and operational at time of inspection. Auditory alarms were functional at time of inspection. Water temperature in bathroom used by residents measured 127.6 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. Required postings observed.
Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NIGHTINGALE CARE HOMES LLC
FACILITY NUMBER: 496804107
VISIT DATE: 11/02/2023
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Continues from LIC809...

Extra hygiene products and linens were available. Cleaning supplies are stored in the locked laundry room. Facility has at least two days of perishable and one week of non-perishable foods. Facility has emergency food and water supplies. Bathrooms had required bath mats and grab bars. LPA/lead staff observed cameras located in three locations in the common areas. Per lead staff, the cameras are not working at this moment, but they have not decided if they are going to proceed to install their own cameras or not. Licensee agreed to notify CCL of any updates and is aware that if they decide to install them, the facility plan of operation and admission agreement informing family of video surveillance will need to be submitted to CCL for review. Medications and medication records were reviewed.

At approximate 10am LPA initiated resident and staff records reviewed. Five out of five staff has an active First Aid/CPR Certificate and staff's annual required training hours. All residents have a current medical assessment on file. One out of five resident's (R1) care plan needs to be updated. Licensee has not completed new Admission Agreements for 4 out of 5 residents. Medications is centrally stored and locked in a cabinet located in the hallway and inaccessible to clients.

Facility agrees to submit updates of the following by 11/30/23:
-LIC 500 Personnel Report
-LIC308 Designation of Facility Responsibility.
-Copy of Liability Insurance
-Control of Property.
-LIC 610 Emergency Disaster Plan (If changes)
-Infection Control Plan (If changes)
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 Lead Staff, Licensee was made aware of citations via phone and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/02/2023 12:33 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/02/2023 at 11:32 AM
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: NIGHTINGALE CARE HOMES LLC
FACILITY NUMBER: 496804107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/lead staff observation, the licensee did not comply with the section cited above in water temperature measured 127.6 F degrees, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee agrees to adjust water heater to ensure that hot water temperature is within regulation and will submit a LIC9098 self-certification form notifying the Department that they are back in compliance with regulation by POC due date to clear deficiency.
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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/02/2023 12:33 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/02/2023 at 11:32 AM
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: NIGHTINGALE CARE HOMES LLC
FACILITY NUMBER: 496804107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Lead staff observation, record review and interview with lead staff, the licensee did not comply with the section cited above in 4 out of 5 resident's admission agreements were not updated after change of ownership, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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The facility will update admission agreements with resident/responsible parties and will submit proof of addendums signed pages to CCL by POC due date
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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Based on LPA/Lead staff observation, records review and interviews with lead staff, the licensee did not comply with the section cited above in 1 out of 5 resident's care plans were not updated within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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The facility will arrange a meeting with resident or their responsible party to update their care plan and will submit proof of signed care plan 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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/02/2023 12:33 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 11/02/2023 at 11:32 AM
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: NIGHTINGALE CARE HOMES LLC
FACILITY NUMBER: 496804107

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/lead staff observation, records review and interview with lead staff, the licensee did not comply with the section cited above by not conducting a fire drill within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Licensee agreed to conduct a fire drill and will submit proof to CCL by POC due date.
Type B
Section Cited
CCR
87211(a)(1)(D)

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/lead staff observation, records review and interview with lead staff, the icensee have not submitted incidents that have occurred to CCL as required, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/30/2023
Plan of Correction
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Facility agrees to send in the required Incident reports to CCL, send in a written statement that they understand requirement and how they will ensure to stay in compliance at all times 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:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


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