Pine Valley Home Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 9:57 am. to conduct an unannounced annual visit. LPA met the Caregiver Ruth Aglasi at the front door and was granted entry. The Administrator Norisa Domilos arrived at 10:30am. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory residents with 1 non-ambulatory resident in care. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 72 degrees. The facility consists of 4 resident bedrooms, and 3 bathrooms, living room, kitchen, and backyard. The bedrooms are furnished with lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 112 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the hallway and inaccessible to the resident. The facility and has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, client rights, and admissions agreements. (Continued on LIC809-C) Client Rights-Information: The facility has client rights information posted in the facility. Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available. Health- Related Services: The facility has a medication logbook, and the facility documents the resident’s medication and in compliance with physician’s orders and regulations. Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 10/24/19. The facility has emergency supply of food and water. Items Discussed: The last fire drill was completed on 10/24/2019. The facility has not conducted any fire drills since which is not compliant with California Code of Regulations. Summary: A deficiency is being cited per Title 22, Div. 6, Chap 8 and listed on LIC 809-D. An exit interview was conducted, Appeal Rights (LIC 9098) along with a copy of this report was provided to the Administrator Norisa Domilos and her signature on this form confirms receipt of these rights.the state’s words, verbatim · CDSS document, Oct 11, 2023

Type of visit: Required - 1 Year

On September 30, 2022, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control. LPA Mixson was greeted and granted entry by Lead Caregiver, Ruth Aglasi introduced self and stated the purpose of the visit. Present in the facility were 2 residents and 2 caregiver. There are currently no cases of COVID-19 within the facility. LPA Mixson toured the facility and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities. LPA Mixson later discussed infection control practices and procedures with Lead Caregiver. An exit interview was conducted and a copy of this report, along with the LIC 811, was given to Lead Caregiver.the state’s words, verbatim · CDSS document, Sep 30, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Carmen Lopez made an unannounced visit to the facility to conduct an annual required licensing inspection. LPA identified herself and was granted entry by Ruth Aglasi, House Manager. LPA met with Ruth Aglasi and discussed the purpose of today’s visit. Licensee Norisa Domilos later arrived. A tour of the facility was conducted inside and out. LPA, accompanied by Licensee Norisa Domilos and House Manager Ruth Aglasi, conducted a general overall inspection, with specific focus on infection control protocols. During today's inspection LPA observations include the following: Symptom screening procedures/ for staff, residents and visitors; posted signs regarding visitor policy, promoting hand washing, cough and sneeze etiquette and other infection control procedures; Hand hygiene practices; testing plan and procedures; plans for containing infections, PPE supplies procedures and training; and disinfection procedures. Based on today’s inspection, no deficiencies were observed. An exit interview was conducted with Licensee Norisa Domilos. A copy of this report, along with the Licensee Rights (01/2016) was emailed to Licensee at the conclusion of the visit. LPA requested Licensee to send LPA an electronic message reply confirming receipt of these documents. LPA requested Licensee Domilos to submit a current Designation of Administrative Responsibility LIC 308, Personnel Report LIC 500 and Emergency Disaster Plan LIC 610-E to the licensing office within 10 business days. Forms available at www.ccld.ca.gov.the state’s words, verbatim · CDSS document, Oct 14, 2021

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.