<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280100627
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:39:57 PM


Document Has Been Signed on 03/03/2022 02:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PINER'S GUEST HOMEFACILITY NUMBER:
280100627
ADMINISTRATOR:PINER, GARYFACILITY TYPE:
740
ADDRESS:1800 PUEBLO AVENUETELEPHONE:
(707) 255-3461
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:28CENSUS: 9DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:29 PM
MET WITH:Care Giver, Maria Perez
Administrator, Dane Reeves		TIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Farhaan Sarangi made arrived at Piner Guest Home unannounced for the purpose of conducting a Required-1 year inspection. LPA was greeted at the door by Care Giver, Maria Perez, and was granted access into the facility.

LPA toured the facility and observed the facility to be in good repair and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. Meals are prepared in the main kitchen. Snacks and drinks are stored in the dining area. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins are stored in a locked closet in the hallway. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged on May 2021. Smoke detectors are hardwired into the fire system and are in working order. Facility has fire sprinklers throughout. Carbon Monoxide detector was present, tested and found to be operational during the inspection. First aid kit/Go bag was appropriate. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a paper towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Facility understands that all beds should be outfitted with mattress pads as per Title 22 Regulations # 87307.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in utility room. Facility was N95 Fit tested, date unknown.

No deficiencies were observed or cited during today's Required 1 year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1