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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800367
Report Date: 06/08/2020
Date Signed: 06/10/2020 09:53:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:COUNTRY INNFACILITY NUMBER:
286800367
ADMINISTRATOR:MACARAIG, ROLANDOFACILITY TYPE:
740
ADDRESS:1109-B LA GRANDE AVENUETELEPHONE:
(707) 252-3392
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:29CENSUS: 16DATE:
06/08/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 PM
MET WITH:Rolando Macaraig/Shannon GayskiTIME COMPLETED:
11:00 PM
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Licensing Program Analyst (LPA) Angela Elliott met with Rolando Macaraig, Licensee and Shannon Gayski, Assistant Administrator for a case management tele-visit. It is being conducted via tele-visit due to COVID - 19 precautions.

Facility self reported on 5/1/2020 R1 was concerned about having another TIA (Transient ischemic attack). Facility contacted 911, R1 was assessed at Kaiser Vallejo and returned to the facility with antibiotics. LPA conducted interviews and requested additional documentation.

No citations for deficiencies issued at this time
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2020
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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