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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804159
Report Date: 07/19/2024
Date Signed: 07/19/2024 02:10:38 PM

Document Has Been Signed on 07/19/2024 02:10 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:GRACIOUS LIVING AT PORTER CREEK LLCFACILITY NUMBER:
496804159
ADMINISTRATOR/
DIRECTOR:		MUNGAI, PHOEBEFACILITY TYPE:
740
ADDRESS:3069 PORTER CREEK RDTELEPHONE:
(707) 569-8137
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 6CENSUS: 4DATE:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Phoebe Mungai, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:25 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Phoebe Mungai. Facility contact information was reviewed.

At approximately 9:30am LPA and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food items in refrigerator found open and not covered such as can of tuna and open onion. One zucchini found with white and blue spotting and 3 others with wilted withered skins, soft and mushy to the touch. One avocado with white spotting with concave skin. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked.

All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Bath mat in resident bathroom showed minimal spotting of a black and brown substance, LPA advised that all bath mats must be clean and free from substances that could be toxic to residents. Water temperature in sink accessible to residents in care measured at 112.7, 111.4, and 110.9 degrees F respectively which is within the allowable range of 105 to 120 degrees F.

Facility has three [3] fire extinguishers, both of which were last inspected 3/22/2024. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted on 6/19/2024. Facility has a backup generator for use during a power outage.

At approximately 10:30am LPA conducted review of 5 staff records. All required documentation present. LPA discussed with Admin their materials used for training. Admin advised the materials are CDs from Community Care Options from 2011.

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: GRACIOUS LIVING AT PORTER CREEK LLC
FACILITY NUMBER: 496804159
VISIT DATE: 07/19/2024
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Continued from 809...

LPA and Admin discussed that materials were passed down from previous owner and staff watch the same CDs each year; therefore, no current or new information is being presented or learned. LPA and Admin discussed choosing new materials through an approved vendor, of which Community Care Options is one. LPA will send Admin a list of other approved vendors from which they may choose to select current and new materials for training.

At approximately 11:30am LPA conducted a review of 4 resident records. R2 and R3 have half rails presents on bed but doctor's orders not on file. LPA and Admin discussed when 1/2 rails are present, a doctor's order must be kept on file.

At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. R1 did not have a Centrally Stored Medication Log (CSML) completed for their medications. Admin advised LPA that hospice provider keeps the CSML for R1, but did not know where hospice provider keeps it and Admin does not have a copy of it. LPA advised a CSML must be maintained at the facility for each resident even when they are on hospice (deficiency cited, see 809D).

Phoebe Mungai Administrator Certificate 7030487740 expires 2/9/2025. All fees are current as of this time.



LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report, LIC308- Designation of Responsibility, and a copy of current Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
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Document Has Been Signed on 07/19/2024 02:10 PM - It Cannot Be Edited


Created By: Christi Coppo On 07/19/2024 at 01:27 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: GRACIOUS LIVING AT PORTER CREEK LLC
FACILITY NUMBER: 496804159

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1 did not have a Centrally Stored Medication Log (CSML) completed and on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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Admin completed CSML for R1 when LPA was at facility.Deficiency cleared.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


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