CWH Santa Rosa

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Alviso conducted a case management to continue the Required- 1 Year visit, of 4/18/23; LPA conducted the continuation visit on 6/1/23 at approximately 9:15am, and met with caregiver Pam Watkins. There are five(5) residents in care. Caregiver Raffia arrived to the facility to help provide, to the LPA, facility records, including resident and staff records. LPA received an updated LIC200 application form, and an updated facility sketch, for the change of capacity from six to five, as only one resident room will remain as a shared room, all others will be private. LPA will request a fire clearance inspection, and notify the licensee when the request is sent out. Per review of the Fire/Disaster records, the last two evacuation fire drills were completed on 2/13/23 and 5/18/23. The LPA is reviewing five(5) of five(5) resident files. The LPA is reviewing six(6) of six(6) staff files. All staff have required criminal record clearance LPA observed that one(1) out of five(5) resident files was not on-site or available for review. Staff could not provide residents file to the LPA. This deficiency will be cited, 87506(b) (b) Each resident's record shall contain at least, all documents required by regulation, see LIC809D Per LPA record reviews, staff had no training and/or had incomplete training. Staff #1, staff #2, staff #4, and staff #5, lack 20 hours of required completed training. Four(4) out of six(6) staff lack required training hours. This will be cited, H&S Code 1569.625(b)(2), see LIC809D. Continued on LIC809C... Per LPA record reviews, staff #1, #4, and #6, lack current first aid per review of records. Three(3) out of six(6) staff lack current First Aid and CPR. Staff do work shifts alone at times, so both first aid and cpr are required. This will be cited, 1569.618(c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times, see LIC809D. LPA observed that one(1) out of six) staff files was not on-site and/or available for review. This deficiency will be cited, 87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain all required documents, see LIC809D LPA reviewed staff records, [4] out of [6] staff lacked eight(8) hours of required/completed medication training per H&S Code. This will be cited, 1569.69(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period, see LIC809D. LPA are requesting the following documents be updated and submitted to CCL by 6/23/2023: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610 - Emergency Disaster Plan Copy of Current Liability Insurance Copy of current Administrator Certificate Copy of updated Infection Control Plan-if any changes Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with caregivers Pam Watkins and Raafia Mazhar Chang. Appeal Rights left with caregiver, with a copy of the LIC809 facility report, to provide to the Licensee/Administrator Catherine Clark.the state’s words, verbatim · CDSS document, Jun 1, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 4/18/23 at approximately 3:00pm, and met with Administrator/Licensee Catherine (Cathy) Clark. Currently there are five(5) residents in care. Facility has an approved dementia plan of operation. There is an approved hospice waiver for one(1) resident. Facility submitted the required infection control plan. Fire clearance is approved for six (6) non-ambulatory, which includes one(1) bedridden, The bedridden is cleared for resident room #3, Al exits were free and clear of obstruction. Fire extinguisher was charged, and with receipt of purchase on 2/28/23. LPA observed six(6) of six(6) smoke alarms, that are also carbon monoxide detectors, all were working properly during the inspection. Administrator stated the home owner has completed the requirements by the Planning Department, to break down and remove the staff/office room that was built without permits, LPA observed the garage is now back to being a one(1) car garage as required. The LPA will request a fire clearance re-inspection which will update records, and also comply with the fire departments request of re-inspection when changes were complete. Administrator will submit an updated sketch to show the changes that have been completed, removal of staff/office room, and changes in resident capacity; Room three(3) is the only shared resident room, and the other three(3) resident rooms are all private resident rooms. Administrator stated that five resident capacity is what the sketch will now show. Administrator to submit, no later than 5/2/23, an updated facility sketch LIC999, and an updated application form LIC200. LPA reviewed Infection Control Plan requirements with the Administrator. This Required 1-Year visit will be continued at a later date.the state’s words, verbatim · CDSS document, Apr 18, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dina Alviso arrived unannounced to conduct a Required-1 Year inspection, and met with Licensee, Catherine Clark (Cathy). This inspection is focused on the Infection Control Procedures and Practices of this facility. There were five(5) residents in care at the facility during this inspection. LPA observed a large entry side table by the front door, with sanitizer, thermometer, and covid 19 screening questions, to screen all staff and visitors. Residents are screened daily, and observed for any changes. Facility was found to be clean, orderly, and at a comfortable temperature with all exits free from obstruction. Fire extinguisher was serviced and tagged as required. Smoke Detectors, five(5), which are also carbon monoxide detectors, were found to be operational during the inspection. There was a sufficient supply of both perishable and nonperishable foods as required. Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications were stored locked making them inaccessible to residents in care. All exit alarms were on exit doors and working properly. All bathrooms had grab bars, and non-slip mat/flooring for bathing as needed. Fire clearance for 5 non-ambulatory, which includes one bedridden approval; Fire clearance approved on 2/12/2020 by Inspector Marcia Belforte. Mitigation plan was received and reviewed by the Department. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). Residents have masks available to them for their use if needed and/or wanted. Administrator stated that all staff are to wear masks at all times. Administrator had a mask on during the inspection. Continued on LIC809C.... LPA observed the caregiver without a mask on as LPA was let into the home, the caregiver didn't put a mask on until the LPA asked the staff to put one as required. The LPA was not screened by the caregiver who let them into the facility as required. The backyard fire exit gate was blocked by a large garbage can. These three(3) deficiencies will be cited, see LIC809Ds. An immediate civil penalty in the amount of $500 is assessed today. LPA are requesting the following documents be updated and submitted to CCL by 4/20/2022: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E - Emergency Disaster Plan LIC999- Facility Sketch-Floor Plan Copy of Current Liability Insurance Copy of current Administrator Certificate Copy of Updated Mitigation Plan 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 the Administrator, Catherine Clark.the state’s words, verbatim · CDSS document, Apr 14, 2022