Linda Falls Guest Home 1

Type of visit: Case Management - Legal/Non-compliance

On 08/05/2026, at approximately 3:15 PM, Licensing Program Analyst (LPA) Julie Florio met with Lino Caramat, Designated Responsible Party for a Case Management - Legal/Non-compliance visit and to follow up on substantiated complaint allegations; complaint number 21-AS-20241011110338. The facility was placed on a non-compliance plan for the following reasons: Failure to seek timely medical care for a resident's worsening wound; and Failure to ensure resident received ongoing medical care for a worsening wound, resulting in resident's hospitalization. LPA toured the facility to ensure residents were safe, secure and that their medical needs are being met. On 03/10/2025, the Department concluded an investigation which alleged that neglect/lack of supervision resulting in severe injury and facility failed to seek timely medical. The licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident and CCR Title 22, § 87465(a)(2) Incidental Medical and Dental Care. At the time of the complaint visit on 03/10/2025, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Continued on LIC809C... Continued from LIC809... Per Welfare and Institutions Code § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation." This is evidenced by the facility failing to ensure the resident’s medical needs were met that resulted in hospitalization for the treatment of pressure injuries and acute sepsis. Today, 08/05/2026, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on 03/10/2025, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report issued. Appeal rights provided. DRP's signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Aug 5, 2026

Type of visit: Case Management - Legal/Non-compliance

At approximately 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived at facility unannounced to conduct a Case Management Legal/Non-Compliance visit and was greeted by staff. Norbert Sacro, Licensee was contacted via telephone and arrived at approximately 11:30 AM. The facility was placed on a non-compliance plan for the following reasons: Failure to seek timely medical care for a resident's worsening wound; and Failure to ensure resident received ongoing medical care for a worsening wound, resulting in resident's hospitalization. LPA toured the facility to ensure residents were safe, secure and that their medical needs are being met. During inspection, LPA observed Staff 1 (S1) assisting in the facility. During a previous visit, LPA observed the same individual present in the facility who stated they were visiting. Upon record review during today's inspection, it was revealed that S1 is cleared and associated to facility and is currently scheduled to complete their health screening, TB test, and first and CPR training in order to bring the facility into compliance with regulations. S1 has not yet completed the required initial 40 hours of training within the required time-frame per regulation, (see LIC809D). LPA also discussed the medication administration training requirements with Licensee and S1. Both conveyed understanding and agreed that S1 would complete all of the required medication administration training prior to S1 administering any medications to residents in care. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, and/or a repeat citation within a 12 month time period, may result in a civil penalty assessment. Exit interview conducted with Licensee whose signature on form confirms receipt. Appeal rights provided.the state’s words, verbatim · CDSS document, Apr 2, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: May 1, 2026

Staff training; legislative findings; contents1569.625(b)(1)....A staff member shall complete 20 hours...before working independently with residents. The remaining 20 hours... shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above where S1's personnel file was observed missing proof of all of the required initial training which poses a potential health, safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2026

Plan of correction: Licensee agrees to self certify that S1 has completed all of the required training to CCL by POC dues date of 05/01/2026.

Type of visit: Case Management - Legal/Non-compliance

At approximately 11:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived at this facility unannounced to conduct a Case Management Legal/Non-Compliance visit and was greeted by staff. Norbert Sacro, Licensee was contacted via telephone and arrived at approximately 11:30 AM. This facility was placed into Non-Compliance for the following reasons: Failure to seek timely medical care for a resident's worsening wound; and Failure to ensure resident received ongoing medical care for a worsening wound, resulting in resident's hospitalization. LPA toured the facility to ensure residents were safe, secure and that their medical needs are being met. No citations issued during today's visit. Exit interview conducted with Licensee whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 6, 2025

Type of visit: Case Management - Annual Continuation

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Annual Continuation inspection and was greeted by Norbert Sacro, Licensee/Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. At approximately 10:30 AM, LPA conducted a walk through of the facility with Licensee/Administrator to follow up on areas of concern noted during previous annual inspection visit dated 08/13/2025. LPA observed the following: Licensee placed a hot water warning sign above the faucet where the water temperature tested above the allowable range of 105 to 120 degrees Fahrenheit bringing the facility into compliance with Title 22 regulations. Licensee installed a bedroom door on the staff bedroom bringing the facility into compliance with regulation. Licensee placed a privacy screen in the shared resident bedroom and had each resident sign an addendum to their admissions agreement bringing the facility into compliance with regulation. Licensee installed locks on the doors and cabinets where items which pose a risk to residents in care are stored bringing the facility into compliance with regulation. At approximately 11:15 AM, LPA conducted file review. Three (3) staff files were reviewed and each contained the required documents per regulation. All staff files reviewed contained proof of current First Aid training. Two (2) of three (3) staff files reviewed were deficient in all of the required annual medication training, (see LIC809D). Four (4) of four (4) resident files reviewed each contained all the required documentation per regulation. Continued on LIC809C... Continued from LIC809... At approximately 2:15 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Licensee states that facility and residents' families work together to coordinate medical and dental appointment and transportation to and from their appointments. Facility does not manage P&I cash resources. Licensee provided LPA with proof of current liability insurance. Facility's fire extinguishers were observed fully charged and were last serviced 09/2025. Licensee provided LPA with facility's emergency disaster plan which was last updated 08/2025. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 - Personnel Roster Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights were provided. Exit interview conducted with Licensee/Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 11, 2025

Type of visit: Required - 1 Year

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by staff. Norbert Sacro, Licensee/Administrator was contacted via telephone and was unable to come to the facility for today's inspection. Licensee/Administrator gave LPA permission to proceed with the inspection with Lino Caramat, staff member and Designated Responsible Party (DRP). Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility has a Dementia Care Plan and is approved for three (3) ambulatory, two (2) non-ambulatory, and one (1) bedridden resident. At approximately 11:00 AM, LPA initiated a tour of the facility with DRP and observed the following: Facility is a two story home, was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated on all facility doors and an evacuation chair at the top of the gated stairway. Water temperatures in residents' bathrooms measured above and blow the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA spoke with Licensee who agrees to bring the facility into compliance. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. LPA observed what appeared to be a Hospice resident and a non-ambulatory resident in the shared downstairs bedroom of the facility which is approved for non-ambulatory and a bedridden resident only. LPA spoke with Licensee who agrees to submit a Hospice waiver request immediately to the Department. Additionally, LPA informed Licensee of the need for a privacy screen of some sort for the Hospice resident and a signed agreement of understanding between the facility and both residents. Licensee agrees to bring the facility into compliance with regulation. Continued on LIC809-C... Continued from LIC809... LPA observed a staff bedroom in the downstairs area of the facility which is missing a bedroom door. Additionally, LPA was informed that night staff also sleep on the facility couch when Licensee is away. LPA spoke with Licensee who agrees to install a bedroom door on the staff room and understands that no staff shall sleep in a common area of the facility per regulation. Cabinets containing cleaning supplies and other items that could pose a risk were observed unlocked. Licensee agrees to ensure these items are secured moving forward. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed residents resting or visiting with loved ones in their rooms or watching TV in the common area. Facility has internet service and the telephone was tested and operational during inspection. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility's fire extinguishers were observed fully charged and were last inspected 09/2024. LPA observed PPE, emergency supplies, a first aid kit, flashlights and a backup generator for emergency preparedness. DRP was unable to access resident and staff files due to Licensee being away from the facility with the keys to the filing cabinet which contains these records. LPA spoke with Licensee and explained that all facility documents and files shall be readily available at the facility and to licensing personnel upon request at all times in order to operate in compliance with regulation. LPA will return at a later date to conduct file and medication records review and follow up on the issues observed and discussed with Licensee today to ensure facility has been brought into compliance with regulation. LPA may issue citations at that time. No deficiencies cited during today's inspection. Exit interview conducted with DRP whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: Office

The California Department of Social Services (CDSS) Community Care Licensing (CCL) Santa Rosa Regional Office conducted am in office, Legal Non-Compliance meeting today 07/02/2025 with Linda Falls Guest Home I, 286802019. Present in the meeting were: Licensing Program Manager, Kimberley Mota, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Julie Florio, and Administrator/Licensee Norbert Sacro. The purpose of this office meeting was to discuss areas of concern in the facility operations the result of substantiated complaint received by the Department on 10/11/2024 and putting Linda Falls Guest Home I facility on a Non-Compliance Conference (NCC) plan. On 03/10/2025 Licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of the Resident and California Code of Regulations (CCR) Title 22, § 87465(a)(2) Incidental Medical and Dental Care. Parties present during the meeting agreed to a NCC plan for 2 years ending 07/02/2025 to bring the facility into compliance. Licensee Administrator confirmed that there are no non-ambulatory residents residing on the second floor of the facility which is in compliance with the facility's fire clearance. Items addressed during the meeting include, but are not limited to, areas of concern: Compliance with California Title 22 Regulations and Community Care Licensing (CCL) Requirements Recent substantiated CCL complaint Seeking Timely Medical Attention Violation Failed to ensure the resident’s medical needs were met which resulted in hospitalization for the treatment of pressure injuries and acute sepsis. Continued on LIC809C... Continued from LIC809... Technical Support Provider (TSP) assistance was offered to Licensees during this meeting. Administrator/Licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49(f), 1548, or 1568.0822. Exit interview conducted with Administrator/Licensee, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 2, 2025

Allegation investigated: Neglect/lack of supervision resulting in a severe injury Faciltiy failed to seek timely medical

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA was greeted by caregiver Lino Caramat as Administrator Norbert Sacro was not present at the time of this visit. LPA reviewed documents and interviewed staff. At approximately 8:45AM, LPA reviewed Resident, R1, file and observed the file did not contain evidence of a medical examination prior to admission, no Pre-admission appraisal and no care plan. R1 was admitted to the facility 05/23/2023. LPA observed the file contained a letter sent to the responsible party on 09/15/2024,stating R1 needed a higher level of care. A similar letter was also in the file dated 09/26/2024. The letter dated 09/26/2024 appears to be a formal 60 day eviction notice. Neither of these documents were sent to Community Care Licensing at the time. LPA observed a handwritten note in the file dated 05/26/2023 explaining a Registered Nurse, W1, came to evaluate R1 for home health services. There was a second note dated 02/09/2024, noting a telephone call to a physician requesting a home health visit commenting on declining health and a worsing wound. There was no documentation of when and what medical treatment was sought. Continued on LIC9099-C... Substantiated Based on records reviewed, LPA observed the Licensee was aware of a worsening pressure injury on 02/09/2024 and sought medical assistance. There are no follow up documents regarding the care of R1. Licensee made an attempt to evict R1 in September 2024 noting concerns with declining health conditions. Based on records available during this visit, there was no evidence Licensee sought medical attention for R1 after the 02/09/2024 telephone call. R1's condition continued to decline until R1 was taken to the Hospital on 10/05/2024. Based on records reviewed, the allegations of Neglect/lack of supervision resulting in a severe injury and Facility failed to seek timely medical are determined to be Substantiated. As a result of these violations, an immediate civil penalty is being issued in the amount of $500.00 Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Lino Caramat and Appeal rights were given. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49 or 1548, 1568.0822.the state’s words, verbatim · CDSS document, Mar 10, 2025 · control 21-AS-20241011110338

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Mar 11, 2025

87465 Incidental Medical and Dental Care: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure R1 received timely medical care for a worsing wound. This poses an Immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee Shall conduct retraining for all staff on the care and supervision of residents. Evidence of completed training shall be submitted to CCLD by 03/11/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Mar 11, 2025

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met as evidenced by: Based on records reviewed, LIcensee did not ensure resident received ongoing medical care for a worsening wound, resulting in residents hospitalizion. This poses an Immediate Health, Safety or Personal Rights risk to persons in care. An immediate Civil Penalty is being issued in the amount of $500.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee Shall conduct retraining for all staff on the care and supervision of residents. Evidence of completed training shall be submitted to CCLD by 03/11/2025.

Type of visit: Case Management - Other

At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility to conduct a complaint investigation. LPA met with caregiver Lino Caramat due to the Administrator being away from the facility. At approximately 8:40AM, LPA observed two residents and one staff in the main living room with jackets and sweaters on, and one resident was observed to have a dripping nose. LPA measured the ambient temperature in the facility and found it was 67 degrees. At approximately 8:45AM, LPA reviewed resident records. LPA observed there was no evidence of a medical evaluation, no Pre-Admission appraisal and no care plan in the file. LPA observed the file contained a letter sent to the responsible party on 09/15/2024, stating R1 needed a higher level of care. A similar letter was also in the file dated 09/26/2024. The letter dated 09/26/2024 appears to be a formal 60 day eviction notice. Neither of these documents were sent to Community Care Licensing at the time. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Lino Caramat and Appeal rights were given.the state’s words, verbatim · CDSS document, Mar 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Mar 21, 2025

87458 Medical Assessment: (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure R1 received a medical assessment prior to admission. This poses a potential Health, Safety or Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee shall submit self certification they have read and understand Regulation 87458. Self certification shall be submitted to CCLD by 03/21/2025. Copy of regulation 87458 provided to Licensee.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c) · Plan of correction due date: Mar 21, 2025

87457 Pre-Admission Appraisal: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not complete an evaluation of residents condition prior to admission and keep it in the file. This poses a potential Health, Safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee shall submit self certification they have read and understand Regulation 87457. Self certification shall be submitted to CCLD by 03/21/2025. Copy of regulation 87457 provided to Licensee.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303 · Plan of correction due date: Mar 21, 2025

87303 Maintenance and Operation: (b)A comfortable temperature for residents shall be maintained at all times.(1)The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement is not met as evidenced by: Based on thermometer reading during visit, Licensee did not ensure the temperature was at least 68 degrees F. Temperature was 67 degrees. This poses a potential Health, Safety or Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee shall submit self certification they have read and understand Regulation 87303. Self certification shall be submitted to CCLD by 03/21/2025. Copy of regulation 87303 provided to Licensee.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87224(f) · Plan of correction due date: Mar 21, 2025

87224 Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on records reviewed, Licensee issued an eviction on 09/24/2024 to R1 and did not forward a copy to CCLD. This poses a potential Health, Safety or Personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 10, 2025

Plan of correction: Licensee shall submit self certification they have read and understand Regulation 87224. Self certification shall be submitted to CCLD by 03/21/2025. Copy of regulation 87224 provided to Licensee.

Type of visit: Office

At approximately 1:40PM, Licensing Program Manager Kim Moto and Licensing Program Analyst Chris Arnhold met with Licensee Norbert Sacro in the Santa Rosa Regional Office. This informal meeting is being held to discuss concerns with the fire clearance status on the facility. Currently facility has a clearance for 3 ambulatory residents in the upstairs section and 2 non-ambulatory/1 bedridden resident in the downstairs area. During the recent annual inspection on 08/07/2024, a non-ambulatory resident was residing in an upstairs, ambulatory, room. Shortly afterwards, the resident moved from the facility. During this meeting, ambulatory status was discussed regarding the definition of ambulatory status based on the LIC 602, Physician Report, and the mental status of the resident. Licensee will submit an updated admission agreement to address the potential change in condition for a resident residing in an upstairs room. This update will be submitted to CCL by 10/11/2024. LPM and LPA discussed the remaining outstanding plan of correction with Licensee. LPA cleared the violation during this meeting. No citations issued during this meeting.the state’s words, verbatim · CDSS document, Sep 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) J Macias arrived unannounced to conduct a required Annual inspection and was greeted by Staff/Caregiver. LPA contacted Administrator Norbert Sacro was not available to come during Annual Inspection and gave permission for caregiver to sign reports. Facility contact information was reviewed.Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently six(6) residents in care. Facility approved/cleared for 3 ambulatory, 2 non-ambulatory, and 1 bedridden. One non-ambulatory, R2 resident is located on the second level of the facility, however fire clearance prohibits non-ambulatory residents on the second floor (deficiency cited, see 809D and *Civil Penalty Assessed*) At approximately 9:30am, LPA and caregiver toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Refrigerated food was not found to be stored in a safe manner with open items not labeled with opened date. Kitchen pantry containing bottled food contained multiple expired items (Kikkoman sweet cooking seasoning exp 12/4/2023, Organic coconut aminos sauce exp 7/6/2021, Worcestershire sauce exp 2/20/2021, Bulls Eye bbq sauce exp 10/11/2020, Sugarman Maple syrup exp 1/17/2020, Sweet chili sauce exp 4/9/2021, chili beans exp 4/21/23, Kraft Parmesan cheese exp 4/23/23 and 9/12/21(deficiency cited, see 809D). LPA observed kitchen pantry cabinet where food was stored to have multiple rodent droppings on every shelf, underneath the kitchen sink and where the potatoes were stored (deficiency cited, see 809D). Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were in good repair. Extra hygiene products and linens were available. Water temperature in sinks accessible to residents in care measured at 101.8, 103.6 degrees F, which is not within the allowable range of 105 to 120 degrees F. (deficiency cited, see 809D). Fire extinguishers were last inspected May 1, 2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drills was conducted June 7 2024. Continued on 809C... Continued from 809... At approximately 10:30am LPA conducted a review of 5 resident records. 4 out of the 6 residents, R2, R4, R5, R6 do not have current Appraisal Needs and Services Plan (LIC625) (deficiency cited, see 809D). R1 does not have a current LIC602 and an Appraisal Needs and Services Plan on file. (deficiency cited, see 809D). At approximately 12:30pm LPA conducted review of (3) three staff records. LPA observed three out of three staff did not have required annual training on file (deficiency cited, see 809D). At approximately 2:00pm LPA and Caregiver conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Facility does not have a current Centrally Stored Medication List on file for residents in care. (deficiency cited, see 809D) Norbert Sacro Administrator Certificate 7006370740 expires 10/31/2024. 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 Liability Insurance Current Lease 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.the state’s words, verbatim · CDSS document, Aug 7, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Alviso conducted a case management visit, on 11/7/23 at approximately 11:23am, and met with Rosita O'Campo, Lead Caregiver. LPA observed another caregiver, Zenaida Narciso, on duty during the inspection. LPA observed a large container of several prescribed medications, as well as over the counter medications out in the open, not locked up, stored in the corner right side of the common area on the lower level. LPA obtained pictures. This deficiency will be cited, 87465(h)(2) Incidental Medical and Dental Care-Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D. LPA observed there are three (3) residents on the upper level, two (2) residents have/use walkers, and one (1) resident is wheelchair bound. LPA observed the inside upper-level stairway entry is open and accessible to residents who are non-ambulatory, there is no barrier for residents’ safety, this is a health and safety hazard to residents in care. LPA observed that the upper-level sliding door leads out to a balcony which at the end of the balcony are steep stairs with no barrier for residents safety, this is a health and safety hazard, deficiency will be cited, Personal Accommodations and Services (d)(4)-The following space and safety provisions shall apply to all facilities: Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents, see LIC809D. LPA observed the facility does not have fire/emergency exits per LPA's inspection, the facility only has stairs inside on the upper floor and outside stairs from the balcony, this is a health and safety hazard to residents in care. This deficiency will be cited, H&S Code Emergency Plans 1569.695 (a)(d) (1)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. An evacuation chair at each stairwell, see LIC809D. Licensee to ensure that all deficiencies are corrected in a timely manner, and all plans of corrections are submitted by due dates, see LIC809Ds. Continued on LIC809C... The Department has contacted the State Fire Department, Fire Department for outside of Napa city limits, regarding information on fire clearance approval; The Department requested information from State Fire Department on fire code requirements for non-ambulatory on a second floor, and required emergency fire exits on a second floor. Emergency and disaster plan, LIC610E, must be reviewed, updated, signed/dated, and submitted to the licensing Department, regarding current residents in care and facility emergency evacuations, including facility having evacuation chairs. This plan is due no later than 11/17/23. All staff must be trained in the updated emergency disaster plan; Staff to be trained in instructions on use of the evacuation chair, ensure staff know how to operate it. Staff are to be trained in the facility policy and procedures, regarding the two sturdy barrier gates. Licensee agreed to install the barrier gates, one at the top of the inside stairs, and one outside at the top of the balcony. Proof of training due by 11/30/23. Include trainer, topics, date/time spent, and attendees. Licensee has agreed to ensure secure sturdy barriers/gates are installed, one inside the facility at the top of the stairs on the second level, and on the outside second level balcony at the top of the stairs.. All staff are to be trained in the policy and use, 24/7, of the gates being kept closed at all times. This must be installed and completed no later than 11/30/23. Licensee has agreed to submit a plan on ensuring sufficient staffing to supervise residents at all times in regard to the stairs inside the facility and the stairs outside off the balcony that currently don't have barriers for residents safety. You will ensure all residents are supervised as needed, 24/7, to ensure health and safety regarding these stair openings, until both the stairs have barriers as required. Residents have the right to access the facility common areas, the Licensee is to ensure sufficient staffing as to not restrict residents' use of the common areas. Please submit this plan including the above no later than 11/9/23. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited, see LIC809D pages. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Exit interview conducted with the Administrator Norbert Sacro. Appeal Rights provided.the state’s words, verbatim · CDSS document, Nov 7, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Nov 8, 2023

87465(h)(2) Incidental Medical and Dental Care-Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met, as evidenced by: LPA observed a large container of several prescribed medications, as well as over the counter medications, of R1, out in the open, not locked up, This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: Administrator to ensure all medications are centrally stored and inaccessible to residents in care. Administrator to hold an in-service regarding facility's medication policy and procedures regarding storage of medications. Follow-up proof of training to be submitted by 11/14/23. POC due 11/8/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(d)(4) · Plan of correction due date: Nov 8, 2023

87307 Personal Accommodations and Services (d)(4)-The following space and safety provisions shall apply to all facilities: Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents.This requirement was not met, as evidenced by: LPA observed there are three (3) residents on the upper level, two (2) residents have/use walkers, and one (1) resident is wheelchair bound. LPA observed the inside upper-level stairs has no barrier, and the upper-level outside balcony stairs has no barrier, this is a health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: Licensee has agreed to install barrier gates, one at the top of the facility upper level inside stairs, and at the top of the stairs off the upper level outside balcony. Plan on getting the barrier gates installed for residents' safety inside and outside of the facility common areas. Submit completion notification to the Department of installed gates no later than 11/20/23. Submit plan of correction by 11/8/23.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.695(a)(d)(1) · Plan of correction due date: Nov 10, 2023

Emergency Plans 1569.695 (a)(d) (1)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. An evacuation chair at each stairwell. This requirement was not met as evidenced by: LPA observed three non-ambulatory residents on the upper level. LPA observed the facility does not have fire/emergency exits per LPA's inspection, the facility only has stairs inside on the upper floor and outside stairs from the balcony, this is a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 7, 2023

Plan of correction: Licensee to ensure that the facility has evacuation chairs to assist in evacuating residents in the vent of an emergency at either the stairs inside the facility on the upper level, and/or the stairs off the balcony on the upper level. Both the stair areas, inside and outside, are the only ways out of the facility's second floor. Licensee to submit copy of receipt of purchase of evacuation chairs, and pictures of the evacuation chairs for the facility. POC due 11/10/23. Reminder-Post up the evacuation chair use instructions where the evac chairs are kept. by stair areas.