286800367-2-7-2025-21-AS-SSTN-DDNTHC-20250207134430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800367
Report Date: 02/07/2025
Date Signed: 02/07/2025 01:44:53 PM

Document Has Been Signed on 02/07/2025 01:44 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	TOTAL ENROLLED CHILDREN: 0	CENSUS: 12	DATE:	02/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Rolando Macaraig		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

NARRATIVE

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Licensing Program Analyst (LPAs) Stevenson and Arnhold arrived unannounced at approximately 9:15 AM to conduct a 1-Year Required Annual Inspection. LPAs was met by administrator Rolondo Macaraig and assistant administrator Shannon Gayski. There were 12 residents in care.
At approximately 9:45am LPAs and care staff toured facility together to ensure health and safety of residents in care. Areas toured included but not limited to: common areas, resident bedrooms, kitchen, common restrooms, outdoor storage areas including locked and fenced pool area. LPAs observed the facility to be a comfortable temperature, clean, odor-free, numerous opportunities for activities were noted and underway with staff. Bathrooms were noted to have the necessary grab bars, non-skid flooring or shower chairs. LPAs observed each bedroom to have the necessary furnishings with working lights and windows with screens.

Facility has a 2-day perishable and a 7-day non-perishable amounts of food and sharps were locked. Hot water temperature was measured within the required range between 105 and 120F. LPAs observed several charged fire extinguishers, hard wired smoke, and carbon monoxide detectors throughout the facility. Meds were centrally stored and locked and in good order. LPAs observed the first aid kit to be complete and ready for use.

LPA reviewed a total of five (5) of 12 residents' files and five (5) staff files.

Resident files reviewed, contained all the required documentation.
5 of 5 staff files reviewed did not contain evidence of completed annual training.
LPAs were given update copies of Personnel Report (LIC500, Affidavit regarding cash resources LIC400, well bacterial testing, updated certificate of Liability Insurance)

LPAs requested current lease agreement to be submitted to CCL within 30 days from this visit.

Continued on 809-C

Kimberley Mota	TELEPHONE: (707) 588-5051
Star Stevenson	TELEPHONE: 707-588-5081
	DATE: 02/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

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: COUNTRY INN	FACILITY NUMBER: 286800367
	VISIT DATE: 02/07/2025

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 26 27 28 29 30 31 32	Continued from 809..... 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, may result in a civil penalty assessment. Appeal rights were given This report was reviewed with and appeal rights were given to administrator Rolando Macaraig

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Star Stevenson	TELEPHONE: 707-588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 02/07/2025 01:44 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: COUNTRY INN	FACILITY NUMBER: 286800367
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2025

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 5 out of 5 staff records reviewed. Files did not contain evidence of annual training, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Licensee to submit self certification of completed staff training by POC date 03/07/2025.

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.

Kimberley Mota	TELEPHONE: (707) 588-5051
Star Stevenson	TELEPHONE: 707-588-5081
	DATE: 02/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025

LIC809 (FAS) - (06/04)

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