Yerba Buena Residential Care Home

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs), Farhaan Sarangi and Christi Coppo arrived unannounced at Yerba Buena Residential Care Home for the purpose of conducting a Case Management-Other inspection. LPAs were greeted at the door by Caregiver Marbella Matos, and was granted access into the facility. Also participating on this Case Management-Other inspection is Assistant Fire Marshall, Kemplen Robbins from City of Santa Rosa Fire Department and Senior Code Enforcement Officer, Cassidy Anderson from the City of Santa Rosa. LPAs, Assistant Fire Marshall and Senior Code Enforcement Officer toured the facility. During the tour, LPAs, Assistant Fire Marshall and Senior Code Enforcement Officer observed a structure in the back of the facility that is NOT STD 850 approved by the Fire Department (See LIC 809D and Civil Penalty). Senior Code Enforcement Officer has condemned the structure in the back of the facility and ordered the occupants/caregivers to vacate the structure. Furthermore, a document provided by the licensee was emailed on August 2, 2023 to the LPA reflecting a City of Santa Rosa Fire Department Inspection report that had falsified verbiage regarding the structure clearance (See LIC 809D). The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed in the amount of $500.00 (See LIC 421M dated for August 21, 2023) Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview conducted with the Administrator and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 21, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Aug 22, 2023

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: Based on the inspection from the LPAs, Assistant Fire Marshall and the Senior Code Enforcement Officer, it was determined that the structure in the back was not STD 850 fire clearance approved. This presents an immediate health, safety and personal rights risk to the residents in care. Civil Penalty Asssessed in the amount of $500.00.the state’s words, verbatim · CDSS document, Aug 21, 2023

Plan of correction: Plan of Correction shall include caregivers to vacate the property in the back. In addition, Administrator to provide a written statement on how future compliance will be met along with an LIC 9098-Self Certification to be forwarded to the LPA. Plan of Correction due on August 22, 2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Aug 22, 2023

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Documents provided by the licensee were emailed on August 2, 2023 to the LPA reflecting a City of Santa Rosa Fire Department Inspection report that had falsified verbiage regarding the structure clearancethe state’s words, verbatim · CDSS document, Aug 21, 2023

Plan of correction: Plan of Correction shall include that the Administrator conducts staff training regarding documents and retaining correct documents to be provided to licensing upon request. In addition, Administrator to provide a written statement on how future compliance will be met along with an LIC 9098-Self Certification to be forwarded to the LPA. Plan of Correction due date August 28, 2023.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Yerba Buena Residential Care Home for the purpose of conducting a Case Management-Annual Continuation Inspection. LPA was greeted at the door by Caregiver, Noel Marayag and was granted access into the facility. Licensee arrived 15 minutes later. During the Case Management-Annual Continuation, LPA reviewed 2 of 2 staff files and found those files to be appropriate during the Required 1 year inspection. LPA reviewed 6 of 6 resident records. However, LPA observed 1 out of 6 residents did not have a physician signature on an LIC 602 (See LIC 9102-Technical Advisory). 6 of 6 Medication Orders were reviewed with the Licensee. LPA interviewed 2 of 2 staff members. LPA interviewed 4 of 6 residents. Remainder of residents were asleep during the inspection. LPA requested the following documents to be sent: LIC 500- Personnel Report LIC 308-Designation of Responsibility LIC 400- Affidavit regarding Client Cash Resources Updated facility sketch Liability insurance Control of Property Resident Roster No deficiencies were observed or cited during today's Case Management-Annual Continuation Inspection. Exit interview was conducted and a copy of this report was given to the facility Caregiver.the state’s words, verbatim · CDSS document, Aug 1, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Yerba Buena Residential Care Home for the purpose of conducting a Required 1 year inspeciton. LPA was greeted at the door by Caregiver, Noel Marayag and was granted access into the facility. During a review of the Guardian Background Clearance Roster, LPA observed that 1 out of 2 staff members did not have a Background Clearance (See LIC 809D & Civil Penalty). Caregiver, Noel Marayag disclosed to the LPA that the Uncleared Adult just started working yesterday, July 24, 2023. LPA attempted to get Identification from the Uncleared Adult, but the Uncleared adult did not have any identification. While setting up the LPA laptop on the kitchen table, LPA observed a camera with audio in the kitchen credenza closest to the fridge monitoring a resident in placement (See LIC 9102-Technical Violation). Caregiver disclosed that the camera was put in by the family. LPA advised to remove the camera. LPA gave Technical Assistance to the facility if the families want to install cameras in the room. LPA and Caregiver toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on October 2022 at the time of the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Auditory Devices were operational during the inspection. First Aid kit cart was inspected and found to be appropriate during the inspection. Water temperature in 3 of 3 residents bathroom measured at 105 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Knives and other hazardous items were locked and inaccessible to residents in care. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Activities menu was available for viewing during the inspection. Medications were centrally stored and locked in the closet. Cleaning products and other toxins are located in the locked laundry room and inaccessible to residents in care. There was a supply of Linens, cleaners, hygiene products and paper products available for residents in care during the inspection. (Report continued on LIC 809C) All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing. Staff files, resident files and medication files will be reviewed at a later date and time. Staff and resident interviews will also be conducted at a later date and time. Emergency Disaster Plan was reviewed. Emergency Generator was observed in the garage. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + or any other infectious diseases in the facility. LPA discussed the Infection Control Plan with the Caregiver and advised to update Infection Control Plan. To update the Infection Control Plan, see below: https://www.cdss.ca.gov/inforesources/forms-brochures/forms-alphabetic-list/i-l LIC 9282 (6/23) – Residential Infection Control Plan - Adult Residential Facilities, Enhanced Behavioral Supports Homes, Community Crisis Homes, Residential Care Facilities for the Elderly, Residential Care Facilities for the Chronically Ill, and Social Rehabilitation Facilities Emergency Disaster Plan was discussed. A review of the Emergency Disaster drill reflects the last time a drill was conducted was on March 2021 (See LIC 9102-Technical Violation). LPA educated the Caregiver regarding the importance of conducting quarterly disaster drills as outlined in Title 22 regulations. The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed (See LIC 421M dated for June 5, 2023) Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview conducted with the Caregiver, appeal rights provided and Caregiver provided this report.the state’s words, verbatim · CDSS document, Jul 25, 2023

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff not fingerprint cleared and/or associated.

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/15/2022 to deliver complaint findings regarding the allegation above. Administrator, Angelica Martinez was not available but was notified of findings over the phone and agreed to have staff sign complaint report. LPA investigated the allegation that staff were not fingerprint cleared and/or associated. During the initial inspection on 11/03/2022 LPA reviewed staff records, personnel reports, staff sign in sheets, and Guardian roster. Record review revealed that Staff 1 (S1) was fingerprint cleared and associated to licensee’s other facility but not Yerba Buena Residential Care Home. S1 has since been associated to the facility. The preponderance of evidence standard has been met; therefore, the above allegation is substantiated. Nothe state’s words, verbatim · CDSS document, Dec 15, 2022 · control 21-AS-20221025101410

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required-1 Year inspection at approximately 1:00 PM, and was initially greeted by staff. Licensee/Administrator, Angelica Martinez arrived shortly The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPA was asked fill out a screening form and sign in. At primary entrance LPA observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff completed Personal Protective Equipment (PPE) and infection control training last year through Kaiser. High touch surface areas are disinfected daily. Due to residents having private rooms they could isolate in their own rooms if they became ill. LPA confirmed facility has necessary PPE and supplies to support a resident in isolation. Licensee plans to fit test staff after undergoing training. Residents' emergency contact information has been updated and staff indicated they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet and in locked cabinets under the kitchen and bathroom sinks. A 30 day supply of medications are locked in administrator's office. The facility has a sufficient supply of PPE located in garage. All exit alarms on exit doors were working properly. Facility is not currently conducting surveillance testing. All staff have received their booster shot and all residents have received their booster shot. Continued on LIC 809C During tour of the facility LPA observed two half rails placed together that ran the full length of a resident's bed. Interview with administrator revealed resident is not receiving hospice services. Administrator provided discharge paperwork indicating the need for bed rails. Paperwork does not specify half or full bed rails. LPA requested the following updated documents: LIC 500 LIC 9020 Emergency Disaster Plan Liability Insurance 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 administrator and a copy of this report printed for the facility.the state’s words, verbatim · CDSS document, May 13, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a case management inspection at approximately 1:00 PM. The purpose of the inspection was to follow up with an incident report received by community care licensing on December 6, 2021. Incident report indicated that a resident, R1 had been transported to the hospital. Administrator was not present at the time of the inspection. Administrator and LPA spoke over the phone. Administrator indicated that R1 was still at the hospital and would be returning back to the facility later this week. Administrator will let LPA know when R1 returns. LPA reviewed R1's file. No deficiencies cited during today's inspection. Exit interview conducted with staff. LPA unable to print. LPA will email copy of this report to licensee.the state’s words, verbatim · CDSS document, Dec 17, 2021

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Erik Gonzalez Campos and Licensing Program Manager (LPM) Kimberley Mota arrived unannounced to conduct an Annual inspection at approximately 12:00 PM, and met with staff Elida Mendoza. The inspection is focused on the Infection Control procedures and practices of this facility. Upon entry LPA and LPM were asked to fill out a screening form and sign in. At primary entrance LPAs observed temperature logs and visitor sign-in sheet. LPA conducted walk through of the facility with Elida Mendoza and observed COVID postings throughout. Mitigation plan has been submitted and approved by Community Care Licensing (CCL). Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, updated infection control guidelines and PINs are communicated to staff verbally. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser. High touch surface areas are disinfected daily. Due to residents having private rooms they could isolate in their own rooms if they became ill. LPA and LPM confirmed facility has necessary PPE equipment and supplies to support a resident in isolation. Residents' emergency contact information has been updated and staff indicated they are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in locked hallway closet and in locked cabinets under the kitchen and bathroom sinks. A 30 day supply of medications are locked in administrator's office. The facility has a sufficient supply of Personal Protective Equipment (PPE) located in administrators office. All exit alarms on exit doors were working properly. Facility is conducting COVID-19 surveillance testing per CCL guidelines. All staff have been vaccinated Continued on LIC 809C Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Some residents also prefer to have meals in their rooms. Common areas are also set up for social distancing. Visits are occurring both inside the facility as well as on the outdoor patio area. Staff confirmed if residents were to go on outings they would be screened for symptoms on their return. No deficiencies cited during this inspectionthe state’s words, verbatim · CDSS document, Jul 9, 2021