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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280100627
Report Date: 02/22/2024
Date Signed: 02/22/2024 02:39:21 PM


Document Has Been Signed on 02/22/2024 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: 7DATE:
02/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Deirdre Villante, SupervisorTIME COMPLETED:
02:45 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual inspection of facility. LPA met with Deirdre Villante, Supervisor of Building. Administrator was called at other building of visit. There is a total of 7 residents with none currently on Hospice.

At approximately 1:45 PM, LPA toured the building and grounds with Supervisor which was found to be clean and in good repair. 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. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Hot water temperature measured between 115.5 degrees F and 117.8 degrees F. within Title 22 acceptable regulation of 105 to 120 degrees F in 5 of 5 resident’s bathrooms while touring facility on 2/22/2024 at aprox 2:00 pm. There was a supply of cleaners, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in bathroom showers. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Fire Extinguisher was found to be last charged on 1/18/2024 at the time of the visit. LPA observed Carbon Monoxide detectors to be operational during the visit. Medication is centrally stored, well organized and secure.

There is a daily activity schedule for residents.

LPA initiated a file review of seven residents files and five personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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