Alf Sanctuary Adult Residential Care

Type of visit: Required - 1 Year

9/12/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Lead Staff, Rayna Yu. Administrator, Maria Buna was contacted and arrived later in the visit. The facility is licensed for 6 non-ambulatory and 1 bedridden resident and a hospice waiver for 2. The facility currently provides care for 4 residents, one of which is receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with Lead Staff, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility exits were equipped with auditory alarms for residents with dementia all of which were found to be functioning. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 11/22/2021 and is in need of inspection. Both smoke detectors and carbon monoxide detectors throughout the facility were tested and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food stored properly. Facility also follows appropriate dietary protocol for resident in care. Toxins, sharps and other items that could pose threat if readily available to residents were kept secured under restroom sinks and storage cabinet in the backyard. Residents were observed engaging in discussion with staff and one another, resting or visited by family. Residents appear to have a positive relationship with staff based on LPA observations. There was a supply of hygiene products, continence products, paper products and clean linens available for residents. All resident bedrooms have lighting & appropriate furnishings. Medications located in a designated cabinet in the kitchen and were found to be secured. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record. Upon count LPA found all administered medication to be in order. LPA also conducted a file review for all residents and found all resident records including physician's report and needs & service plans updated. Lastly, facility conducts and records emergency disaster drill on a quarterly basis. Continued onto LIC809-C LPA toured the backyard and found two emergency exits located on the sides of the home to be unobstructed. LPA observed separate shed located in the backyard that the facility staff utilize for overnight sleeping during shift changes. Upon LPA interview, staff confirmed using the quarters for overnight sleeping into the following morning shifts. The facility does not have an updated fire clearance or facility sketch approving the use of the shed for living and staff sleeping quarters. Suisun City Fire Marshall, Jose Colin was contacted and arrived at the facility to make additional observations of the staff living quarters. LPA and Fire Marshall both concluded observations and determined that the facility will require a fire clearance and facility sketch. Staff quarters are to be immediately vacated. Fire Marshall will be notifying code enforcement. **Immediate Civil Penalty assessed in the amount of $500 due to fire clearance violation. Deficiency 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. LPA requested the following documents be sent to CCL by COB 10/12/2023: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Liability Insurance Control of Property Deficiency 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.the state’s words, verbatim · CDSS document, Sep 12, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Alf Sanctuary Adult Residential Care for the purpose of conducting a Required 1 year inspection. LPA was greeted at the door by Caregiver, Deo Bardon, and was granted access into the facility. LPA and Staff Member, Reyna Yu toured the facility and found the facility to be clean and well organized. Grounds free of any apparent hazards. All exits unobstructed. Hot water temperature measured at 116 F degrees in bathrooms. Fire extinguishers was dated for September 2021. Smoke and Carbon Monoxide detectors were tested on September 24, 2021 with a passing result. Disinfectants and medications locked and stored away. First Aid kit was found to be appropriate during the inspection. Fresh and non-perishable food in adequate supply. No bodies of water on premises. No firearms stored at facility during the inspection. Sufficient linens and bedding for the residents were observed. Bathrooms clean and adequately stocked. Medications were stored and inaccessible to residents according to regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the inspection. Dangerous items were stored inaccessible to residents. There was a supply of cleaners, hygiene products and paper products available for residents. The bathroom designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. All residents bedrooms have lighting & appropriate furnishings, and facility has mattress pads available for residents as required by Title 22 Regulations. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has sufficient PPE stored underneath the credenza in the kitchen/dining room. Facility is in the process of being N95 Fit tested for staff members (See LIC 9102). LPA requested the following documents: (Report continued on LIC 809C) LIC 500- Personnel Report LIC 308- Designation of Responsibility LIC 309- Administrative Organization LIC 400- Affidavit regarding Client Cash Resources Last Disaster Drill conducted Updated facility sketch Updated Emergency Disaster Plan (LIC 610D) Surety Bond Most up-to-date Liability insurance Control of Property Register of residents LPA was made aware of an Administrator change during the Required-1 year inspection. LPA requested the following documents to be sent to his attention: LIC 308 Designation of Facility responsibility (designation of who is the administrator) Administrator Certificate First Aid Certificate Administrator Resume (in small facilities if possible) LIC 500 Personnel Report LIC 501 Personnel Record LIC 503 Health Screening Report - personnel (keep on facility staff file to be reviewed) TB test that shows "negative" (keep on facility staff file to be reviewed) LIC 508 Criminal Record Statement LIC 9182 Criminal Record Exemption Transfer Request Copy of Personal ID No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was given to the facility Staff Member, Reyna Yuthe state’s words, verbatim · CDSS document, Sep 12, 2022

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

At approximately 1:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Administrator, Maria Buna. LPA Felias discussed with Administrator the flooding that occurred on 3/31/2022, which damaged a portion of Room 1, a double occupancy room, and Room 1's bathroom and shower. Per review of incident report, Facility immediately called Plumber company to check damaged area and to fix shower drain. Affected areas were cleaned, disinfected, and dried. Per conversation with Administrator, water from the washing machine backed up into the shower drain and flooded the surrounding areas. Plumber company stated that the floors will need to be opened to assess the damages and observe what repairs will be needed. Facility met with a claims adjuster on 4/5/2022 and is waiting for insurance coverage to be confirmed. Facility has scheduled for repairs which will begin once insurance amount is confirmed. Estimated time to complete repairs is approximately 3 days. The residents that resided in the affected room will be moved to the facility's vacant single private room to be temporarily shared until repairs are complete. LPA and Administrator discussed contacting the Fire Department to confirm if the private single room can be a shared double room. Facility to send an updated facility sketch if approved. During visit, Fire Marshal, Jose Colin, arrived to inspect the rooms and gave approval to facility to move residents to vacant room. LPA to monitor situation closely. Facility to email LPA with updated facility sketch. No Deficiencies cited during this visit.the state’s words, verbatim · CDSS document, Apr 7, 2022

Type of visit: Post Licensing

Licensing Program Analysts (LPAs) Willis and Felias arrived unannounced to conduct a Post Licensing Inspection and met with Staff Member Rayna Yu, Administrator Maricel Aquino was available by phone. Upon arrival, LPAs temperature was checked and documented and LPAs were asked to sign in. LPAs conducted a walk-through of the facility and observed the following: Facility has Covid-19 posters throughout the facility including on the front door and hand washing signs in the bathroom. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer was available in common areas. Staff wear masks while in the facility. Observed staff had masks on during this visit. Per conversation with Administrator, Live-in Staff are screened for Covid-19 symptoms at the beginning of their shift and Residents are screened twice a day. LPAs and Administrator discussed resident activities and visitation. Commonly touched surfaces are disinfected twice per day and as needed.. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including surgical masks, gloves and hand sanitizer. Staff have been N95 fit tested. Facility maintains a 30 day supply of medication. . No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Feb 3, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Victoria Willis arrived announced to conduct a Pre-Licensing Inspection and met with Applicants, Maricel Aquino and Paulino Buna. Upon arrival, LPA observed a Covid-19 poster on the front door. Once inside, LPA observed multiple Covid-19 posters and a screening station for Covid-19 symptoms that included sign in binders for staff and visitors and a thermometer. Facility is a one story residence with four single bedrooms, one shared bedroom, three bathrooms and common areas. All resident bedrooms are furnished per regulation with a bed, lamp, dresser/closet, chair and bedside table. Bathroom showers have a non-skid shower floor with a bath mat and bathrooms have grab bars to ensure resident safety. Water temperature in bathrooms read at 110, 108 and 105 degrees F which are within regulation of 105 & 120 degrees F. Facility has sufficient items used for meals. Facility has a designated locked drawer for knives or other sharp objects. Perishable and non-perishable foods observed per regulation. Freezer and refrigerator temperatures read within regulation. Facility has a locked desk in the kitchen used for centrally stored medications and files. There is an additional hallway closet that will also be used for files. Cleaning supplies and toxins will be locked in a cabinet in the laundry closet. Other items that may pose a risk to residents in care are locked in an outside shed. Facility backyard has multiple areas for visiting and activities. Facility has a side area that has some uneven ground. Facility is actively working on the area and will be making a pathway. LPA suggested making the area off limits to potential residents until the area is finished. Facility received an approved fire clearance dated September 24, 2021 that allows for up to six non-ambulatory residents and one bedridden resident. Smoke and Carbon Monoxide detectors were tested and operational. Fire extinguishers have been serviced in the last year. Facility has emergency lighting in hallways. LPA confirmed that contents of the facility first aid kit were sufficient and that facility has emergency lighting in case of a power outage. LPA discussed the facility Emergency Disaster Plan with applicant. Facility has submitted their Covid-19 Mitigation Plan. LPA confirmed that Applicant is familiar with Guardian and has read the most recent Provider Information Notices (PINs) that the department sent out regarding Covid-19 vaccinations and visitation. Component III is waived due to Applicant being a current Licensee. LPA will notify Application Unit so application process may proceed.the state’s words, verbatim · CDSS document, Nov 15, 2021

Type of visit: Office

Facility Type: RCFE Application Type: INITIAL Capacity: 0006 Census (if any clients in care): COMP II by CAB successfully completed Method: Telephone call COMP II Participant: MARICEL AQUINO Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID . During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Oct 27, 2021