286800367-1-8-2026-21-AS-JFLO-DQ63Z3-20260108174053

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800367
Report Date: 01/08/2026
Date Signed: 01/08/2026 05:41:09 PM

Document Has Been Signed on 01/08/2026 05:41 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:	COUNTRY INN		FACILITY NUMBER:	286800367
ADMINISTRATOR/ DIRECTOR:	MACARAIG, ROLANDO		FACILITY TYPE:	740
ADDRESS:	1109-B LA GRANDE AVENUE		TELEPHONE:	(707) 252-3392
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY: 29		CENSUS: 14	DATE:	01/08/2026
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Rolando Macaraig, Administrator		TIME VISIT/ INSPECTION COMPLETED:	06:00 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 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual continuation inspection and met with Rolando Macaraig, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with fourteen (14) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan and a Hospice waiver for three (3). At approximately 11:00 AM, LPA initiated a tour of the community with Administrator and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to residents. Administrator agrees to ensure all closets containing cleaning supplies and other items that could pose a risk remain inaccessible to residents in care at all times. The community has at least two days of perishable food and one week of non-perishable foods. Medications were centrally stored and administrator agrees to ensure they are secured and inaccessible to residents at all times. There are covered seating areas and outdoor space for activities. LPA observed residents watching TV, resting in their rooms, and one playing cards on their computer. Facility has internet service and an internet access device available for resident use. Facility's telephone was observed operational during inspection. The community's fire extinguishers were observed charged and were last serviced 12/2025. Sprinklers and Smoke and Carbon Monoxide detectors were last inspected by a third party vendor 08/2022, which passed in all categories. Administrator agrees to ensure facility conducts emergency/disaster drills no less than quarterly in order to operate in compliance with regulation. continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: COUNTRY INN	FACILITY NUMBER: 286800367
	VISIT DATE: 01/08/2026

NARRATIVE

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Continued from LIC809...
LPA observed facility's infection control plan and emergency disaster plan which was last updated 01/2023. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community. Facility has multiple portable backup generators and an external defibrillator for emergency preparedness.

At approximately 1:00 PM, LPA reviewed five (5) resident records and five (5) staff records. Three (3) of five (5) residents' records were missing a current appraisal needs and services plan (see LIC809D), and two (2) of five (5) residents' records were missing a current physician's report as required for those residents per regulation, (see LIC809D). One (1) of five (5) staff records reviewed were missing proof of the required intial 40 hours of training, and four (4) of five (5) were missing proof of the required 20 hours of annual training. One (1) of five (5) staff files reviewed was missing a job application, and one (1) of five (5) was also missing a physician's health screening and proof of CPR/FA certification, (see LIC809D).

Medication records were reviewed and were observed managed and stored in compliance with regulation. Facility works with residents and their families to coordinate medical and dental visits as well as transportation to and from appointments. Facility does not manage P&I cash resources but has a bond.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
-LIC500 - Personnel Report (updated)
-LIC610D - Emergency Disaster Plan (updated)
-A copy of facility's current liability insurance
-Emergency Disaster Drill Conducted (current)

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12 month period, may result in a civil penalty assessment.

Exit interview conducted with Administrator whose signature on form confirms receipt of documents. Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/08/2026 05:41 PM - It Cannot Be Edited

Created By: Julie Florio On 01/08/2026 at 04:55 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: COUNTRY INN	FACILITY NUMBER: 286800367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

Personnel Records

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 5 out of 5 staff files reviewed and found missing 1 or more of the required documents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2026
	Plan of Correction
1 2 3 4	Licensee to submit proof of a physician health screening and CPR/FA certification for S1; a signed personnel report for S4; and proof of the required initial and annual training for S1, S2, S3, S4, and S5 to CCLD by POC due date 02/13/2026.

Type B

Section Cited

CCR

87463(h)

Reappraisals

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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 2 out of 5 resident records reviewed and found missing a current physician's report as required for these residents which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2026
	Plan of Correction
1 2 3 4	Licensee to submit proof of a current physician's report for R2 and R4 to CCLD by POC due date of 02/13/2026.

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

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Julie Florio
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/08/2026 05:41 PM - It Cannot Be Edited

Created By: Julie Florio On 01/08/2026 at 04:55 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: COUNTRY INN	FACILITY NUMBER: 286800367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(i)

Reappraisals

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. 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 3 out of 5 resident records reviewed and found missing a current appraisal needs and services plan which poses potent ial health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2026
	Plan of Correction
1 2 3 4	Licensee to submit a current appraisal needs and services plan for R1, R2, and R4 to CCLD by POC due date of 02/13/2026.

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.

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Julie Florio
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2026

LIC809 (FAS) - (06/04)

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