286800687-3-23-2022-21-AS-FSAI-CCSRWC-20220323132256

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800687
Report Date: 03/23/2022
Date Signed: 03/23/2022 01:23:03 PM

Document Has Been Signed on 03/23/2022 01:23 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:	CELEBRITY HAVEN II		FACILITY NUMBER:	286800687
ADMINISTRATOR:	ANDREW EUGENIO		FACILITY TYPE:	740
ADDRESS:	2212 TROWER AVE.		TELEPHONE:	(707) 251-5722
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 4	DATE:	03/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:28 AM
MET WITH:	Prospective Administrator, Alma Eugenio Fuentes		TIME COMPLETED:	01:20 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	Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Celebrity Haven II unannounced for the purpose of conducting a Required-1 year inspection. LPA was met at the door by Prospective Administrator, Alma Eugenio Fuentes who granted access into the facility. Upon arrival, LPA observed the Administrator not wearing a facial covering, (See LIC 9102) LPA toured the facility with the Administrator, LPA observed the facility to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. There are special provisions made for individuals with special dietary needs. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Water temperature measured at 130.1 degrees falling out of range (See LIC 9102). LPA requested a water log for 7 days. Fire extinguishers was inspected on 10/2021. First Aid kit was appropriate at the time of the inspection. Smoke detectors were tested and found to be in working order. Carbon Monoxide detectors were present and found to be operational during the inspection. Medication is centrally stored and secured. The facility serves residents with dementia and has a plan of operation for care and programming. Facility understands that all beds should be outfitted with mattress pads as per Title 22 Regulations # 87307. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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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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: CELEBRITY HAVEN II	FACILITY NUMBER: 286800687
	VISIT DATE: 03/23/2022

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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Mitigation Plan reviewed and approved at the facility. Disaster Drill last conducted on February 2022. Facility has extra PPE supply on hand. Facility will be in the process of obtaining N95 Fit . Administrator will be putting more signs and revamping her symptom screening questions.

LPA requested the following documents be sent to CCL:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

No deficiencies cited during this inspection. Exit interview was conducted and a copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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