286800687-2-10-2023-21-AS-EGCS-CNWRUK-20230210122004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800687
Report Date: 02/10/2023
Date Signed: 02/10/2023 12:20:51 PM

Document Has Been Signed on 02/10/2023 12:20 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:	FUENTES, ALMA		FACILITY TYPE:	740
ADDRESS:	2212 TROWER AVE.		TELEPHONE:	(707) 251-5722
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 2	DATE:	02/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Alma Fuentes		TIME COMPLETED:	12:25 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) Erik Gonzalez Campos arrived unannounced on 02/10/2023 to conduct a required - 1 year inspection. This inspection is focused on the infection control practices and procedures of this facility. LPA met with administrator, Alma Fuentes. LPA toured building and grounds which were clean and in good repair. Exits and walkways were free from obstructions. Facility had sufficient perishable and non perishable food. Toxins were kept locked and secured. Medications were kept locked and secured. Resident bedrooms were furnished as necessary. Bathrooms had necessary grab bars and non slip mats. Fire extinguishers were charged and current. Smoke and carbon monoxide detectors were present and operational. Staff and residents are fully vaccinated and boosted. High touch surface areas are disinfected daily. LPA observed 4 staff during the inspection. Interview with Staff 1 (S1) revealed that he does not have a valid fingerprint clearance and that he resides at the facility. S1 does not provide direct care for residents. LPA had a conversation with Napa Ombudsman and S1 during the inspection. LPA informed S1 that per regulation he cannot reside at the facility as a staff without a fingerprint clearance and association. S1 left the facility during the inspection. LPA and administrator reviewed regulation 87465 (Incidental Medical and Dental Care). Regulation requires record of each dose given of a PRN medication is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. Regulation does not require a medication administration record for other medications. Continued on LIC 9099C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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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Document Has Been Signed on 02/10/2023 12:20 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CELEBRITY HAVEN II	FACILITY NUMBER: 286800687
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(1)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, 1 out of 4 staff present at the facility did not have a valid criminal record clearance and association to the facility.
	POC Due Date: 02/10/2023
	Plan of Correction
1 2 3 4	S1 was removed from the facility during the inspection on 02/10/2023 and will not return until he obtains a valid fingerprint clearance and association to the facility.

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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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: 02/10/2023

NARRATIVE

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

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

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal rights were provided.

Exit interview conducted with administrator. Reports emailed to facility.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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