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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800367
Report Date: 12/15/2022
Date Signed: 12/15/2022 01:19:45 PM


Document Has Been Signed on 12/15/2022 01:19 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: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: 14DATE:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Adminstrator, Rolando MacaraigTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection. This inspection was focused on the infection control practices and procedures of this facility. LPA met with administrator, Rolando Macaraig. LPA observed necessary COVID postings and screening materials at the front entrance. Screening procedure is required for all staff and visitors.

LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. LPA observed sufficient perishable and non perishable food. Toxins were locked and secured. Medications were locked and secured. Fire extinguishers inspected were last charged on 11/15/2022. Administrator confirmed facility has necessary PPE to support a resident in isolation. Local Public Health has provided staff with PPE and infection control training. LPA and administrator discussed training requirements for staff and resident record keeping. LPA and administrator discussed required documentation for hospice equipment like bed rails.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 Designation of Administrative Responsibility
LIC 610 Emergency Disaster Plan
LIC 500 Personnel Report
LIC 9020 Resident Roster
Evidence of Liability Insurance
Admin Certificate

Exit interview conducted with administrator. Report was emailed to administrator. No deficiencies observed 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: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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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