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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280100627
Report Date: 02/02/2023
Date Signed: 02/02/2023 11:14:02 AM


Document Has Been Signed on 02/02/2023 11:14 AM - 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:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lead Staff, Jennifer AndersenTIME COMPLETED:
11:15 AM
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) Erik Gonzalez Campos arrived unannounced on 02/02/2023 to conduct a required - 1 year inspection. This inspection is focused on the infection control procedures and practices of this facility. LPA met with Lead Staff, Jennifer Andersen.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. Facility is screening visitors and staff at the front entrance. Facility has a sufficient amount of personal protective equipment to support a resident in isolation. Facility has conducted infection control training with staff. Staff and residents are fully vaccinated and boosted. Facility had a sufficient amount of perishable and nonperishable food. Carbon monoxide and smoke detectors were observed throughout the facility. Fire extinguishers inspected were charged and current. Toxins were locked and secured. Medications are centrally stored and secured.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:
LIC 308 Designation of Facility Responsibility
LIC 610 Emergency Disaster Plan
Evidence of Liability Insurance
LIC 500 Personnel Report
LIC 9020 Resident Roster

Facility to submit documents for new administrator once new admin is hired.

Exit interview conducted with Jennifer Andersen and a copy of this report emailed to the facility.
No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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