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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 280100627
Report Date: 02/28/2024
Date Signed: 02/28/2024 02:14:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/28/2024 02:14 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:
02/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Deirdre Villante, SupervisorTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shannan Hansen arrived at 10:30 AM to complete an unannounced annual inspection and was welcomed by staff Mary R. Staff called Supervisor Deirdre Villante who arrived shortly after. There is a total of 7 residents in care, no dementia and none on hospice.


A review of seven residents & four staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 11:00AM on 2/28/2024 and learned that 7out of 7 residents do not have update reappraisal/needs & care plan on file at this time (see LIC809-D) and 1 out of 7 residents (R1) does not have a Physicians Report (602) as required by Title 22 Regulation (see LIC809-D).

Medications were centrally stored in a locked medication cabinet in the facility medication room. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 2/28/2024 at 1:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate; although LPA advised during original inspection on 2/22/24 not to pre-pour medications, during today’s inspection facility had pre-poured medication again (see pics & see LIC809-D).

LPA conducted a sample review of staff records at 12:00PM on 2/28/2024 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1st Aid certification for all staff. Gary Piner, Administrator Certificate # 6012080740 is pending, payment was received 11/6/2023. Smoke detectors are hardwired into the fire system with fire sprinklers throughout. Fire Records indicate last inspection was conducted 3/2023.

Continue to LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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Document Has Been Signed on 02/28/2024 02:14 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
CCLD Regional Office, 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: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
87463(c)

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87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by:
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Administrator to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date 3/8/2024.
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Based on LPA/Administrator's file review showing that resident's care plans for 2 out of 2 residents (R1 - R7) were not been performed and signed by the resident of their representative within last 12 months. This is a potential risk to the health and safety of residents in care.
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Type B
03/08/2024
Section Cited
CCR87458(a)

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87458(a) Medical Assessment. Prior to accepting a person as a resident the licensee must obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. ** This requirement was not met. Based on LPAs record review
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Supervisor/Administrator agrees to review resident records and make sure R1 has 602 in file and submit copy to CCL by POC due date of 3/08/2024.
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the facility did not ensure Resident (R1) had submitted a completed medical assessment in their file, which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2024 02:14 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
CCLD Regional Office, 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: 02/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
CCR
87465(h)(5)

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87465(h)(5) Incidental Medical and Dental Care -(h)The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Facility to ensure that medications are not transferred between containers at any time, per regulation medications are to remain in origianl containers. Licensee to ensure all staff are retrained in medication procedures, submit proof of training with Signatures of Staff, dates, & training type by 3/8/24.
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This requirement was not met as evidenced by: LPA observed all residents medications had been prepoured into plastic containers which were to be given to the residents as stated. Medications are to remain in original containers. This is a potenitial risk to health & safety and/or personal rights risk to residents in care.
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Type B
03/08/2024
Section Cited
HSC1569.695(c)

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1569.695(c)A facility shall conduct a drill at least quarterly for each shift..type of emergency covered in a drill shall vary ... Documentation of the drills shall include date,type of emergency covered by the drill, and names of staff participating in the drill.

This requirement is not met as evidenced by:
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Facility to ensure that facility will conduct quarterly disaster drills as required by Health & Safety Code. Licensee to submit to CCL proof of disaster drill conducted with the facility by POC date of 3/8/2024
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This requirement is not met as evidenced by: Based on interview, the licensee did not comply w/section cited above in 1 of 1 facility drill which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 280100627
VISIT DATE: 02/28/2024
NARRATIVE
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LPA reviewed Licensing Information System (LIS) with Supervisor who stated that is current and updated at this time; no need to change any of the information. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have not been conducted quarterly with the last one being conducted prior to 7/2023 (see LIC809-D).

Appeal Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 3/15/2024:

Copy of Annual Sprinkler Inspection
LIC 308 Designation of Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Control of Property Lease/Grant Deed
Copy of Administrator’s Certificate
Proof of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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