280100627-2-19-2025-21-AS-EMAO-DE2UHW-20250219143638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 280100627
Report Date: 02/19/2025
Date Signed: 02/19/2025 02:36:52 PM

Document Has Been Signed on 02/19/2025 02:36 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	PINER'S GUEST HOME		FACILITY NUMBER:	280100627
ADMINISTRATOR/ DIRECTOR:	PINER, GARY		FACILITY TYPE:	740
ADDRESS:	1800 PUEBLO AVENUE		TELEPHONE:	(707) 255-3461
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY: 28	TOTAL ENROLLED CHILDREN: 0	CENSUS: 8	DATE:	02/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:20 AM
MET WITH:	Deirdre Villante, Supervisor		TIME VISIT/ INSPECTION COMPLETED:	02:45 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	At approximately 10:20am, Licensing Program Analysts (LPAs) Elias Magdaleno and Chris Arnhold arrived unannounced to conduct a required 1-year annual inspection and were greeted by Supervisor Deirdre Villante. Facility is a Residential Care Facility for the Elderly (RCFE) with eight (8) residents in care. Facility has a Hospice waiver for two (2), with no Hospice residents currently in care, and is approved for all non-ambulatory residents. At approximately 10:45am, LPAs initiated a tour of the facility with Supervisor and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 1/27/2025. Water temperatures measured 116.2 degrees F in room 200 and 123.4 degrees F in room 214, a discussion was had with supervisor about water temperature. LPAs observed a supply of clean linens, 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. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPAs observed at least a 2-day supply of perishable food, 7-day supply of non-perishable food, and emergency water supplies. Per discussion with Supervisor, breakfast is made in facility with lunch and dinner sourced from off-site facility elsewhere on property. Food was found to be stored in a safe manner with open items covered. LPAs observed a piano, puzzles, and a movie room accessible to residents. Outdoor seating and tables are available to residents weather permitting. Internet service available, discussion had with Supervisor about acquiring a shared internet accessible device. Continued 809C...

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Elias Magdaleno	TELEPHONE: (707) 588-5045
	DATE: 02/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PINER'S GUEST HOME	FACILITY NUMBER: 280100627
	VISIT DATE: 02/19/2025

NARRATIVE

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Continued from 809...

At approximately 12:00pm LPAs conducted review of five (5) resident records. All required documentation present.

At approximately 12:45pm LPAs conducted a review of five (5) staff records. Three (3) of five (5) staff did not have training hours complete.

At approximately 1:40pm LPAs and Supervisor Deirdre Villante conducted a spot check of medication and medication records. Medication is centrally stored and locked.

Gary Piner Administrator Certificate 7034473740 expires 12/01/2025. All fees are current as of this time.

LPAs and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan, No new updates. Facility’s last quarterly disaster drill was conducted on 2/3/2025.

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 Supervisor. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

Liability Insurance
LIC500- Personnel Report
LIC308- Designation of Responsibility

Exit interview conducted with Supervisor and a copy of this report was given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Elias Magdaleno	TELEPHONE: (707) 588-5045
LICENSING EVALUATOR SIGNATURE:	DATE: 02/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/19/2025 02:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PINER'S GUEST HOME	FACILITY NUMBER: 280100627
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in three out of five staff files reviewed. Documentation of annual training was not present which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/19/2025
	Plan of Correction
1 2 3 4	Licensee to ensure staff receive annual training. Supervisor shall conduct file review of all staff records to ensure the inclusion of required documentation. Licensee to create written plan describing how facility will ensure training compliance. Self certification of plan to complete staff training and files have been reviewed by Plan of Correction due date 3/19/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Elias Magdaleno	TELEPHONE: (707) 588-5045
	DATE: 02/19/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025

LIC809 (FAS) - (06/04)

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