286800687-4-15-2025-21-AS-JFLO-DFS2Q7-20250415173527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800687
Report Date: 04/15/2025
Date Signed: 04/15/2025 05:35:35 PM

Document Has Been Signed on 04/15/2025 05:35 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:	CELEBRITY HAVEN II		FACILITY NUMBER:	286800687
ADMINISTRATOR/ DIRECTOR:	FUENTES, ALMA		FACILITY TYPE:	740
ADDRESS:	2212 TROWER AVE.		TELEPHONE:	(707) 251-5722
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	04/15/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Alma Fuentes, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:45 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 10:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by facility Staff. Alma Fuentes, Administrator, was contacted via telephone and arrived within approximately five minutes. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for one (1), and is approved for six (6) residents. Facility does not currently have any Hospice residents in care. At approximately 10:45 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured slightly above the allowable range of 105 to 120 degrees F per Title 22 regulations. Administrator agrees to monitor the temperatures to operate within regulation. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. However, LPA observed supplements in the medicine cabinet of an unlocked staff bathroom and an open bottle of wine in the facility refrigerator. Administrator had staff secure both immediately. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA inspected three locked sheds in the backyard which contained care equipment, tools, and chemicals. LPA also observed two trailers on the premises which are currently being used for staff living quarters. Continued on LIC809-C...

Bethany Moellers	TELEPHONE: (707) 588-5040
Julie Florio	TELEPHONE: (707) 588-5026
	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

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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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: CELEBRITY HAVEN II	FACILITY NUMBER: 286800687
	VISIT DATE: 04/15/2025

NARRATIVE

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Continued from LIC809C...

LPA observed residents in the common area and in their bedrooms. Administrator states staff engage residents in daily chair exercises, facilitate games time, coordinate musicians performing in the facility and more. Facility telephone was tested an operational during inspection.

Facility's fire extinguisher was observed charged and was last serviced 10/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 1/2025. LPA observed the facility's infection control plan and a supply of PPE. Facility has a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan last updated 02/2025.

LPA observed structural changes within the facility to resident bedroom number one (1) which now has an internal wall and door installed; resident living in a room cleared for staff, and two trailers currently being used for staff living quarters that are not accurately reflected on the facility sketch and are not on the current fire clearance as required per regulation. LPA informed Administrator that any required permits for the structural changes will need to be obtained, if applicable, prior to Administrator submitting a new facility sketch to Licensing requesting a new fire clearance. Administrator agrees to keep LPA informed on their progress.

LPA reviewed five (5) resident files and five (5) staff files. Five (5) of five (5) staff files were observed missing proof of CPR and/or First Aid training from an approved American Red Cross provider as required per regulation. LPA observed no personnel records maintained at the facility for the Licensee who the Administrator states works at the facility occasionally and who performs staff in-service training sessions in her role as a registered nurse. Additionally, Staff 4 (S4) was missing proof of a health screening. Five (5) of five (5) resident files were reviewed and the file for Resident 5 (R5) observed with a wound on their right foot, contained a pre-appraisal from 2017 when the resident was admitted which states that the wound was a "stage II" wound. No orders, exceptions, care notes, or other required documents were observed. Further, based on file review, LPA discovered that Resident 2 (R2) has a suprapubic catheter. LPA did not observe an exception or any care notes related to this. LPA will return to the Department and conduct further file review and gather more information regarding the above residents.

Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

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: CELEBRITY HAVEN II	FACILITY NUMBER: 286800687
	VISIT DATE: 04/15/2025

NARRATIVE

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LPA observed four (4) of four (4) resident records missing a consent for emergency medical treatment at required per regulation as well as three (3) of five (5) residents files were observed missing physician's orders for a hospital bed with half rails as said beds were observed in use by all residents in the facility during today's inspection.

LPA reviewed medications and medication logs which were observed stored and maintained within regulation. Facility does not manage P&I.

Administrator stated they would like to apply for a change of ownership sometime this year under a new entity name and LLC.

LPA will consult with Licensing Program Manager and determine whether an in office meeting is indicated. LPA will issues citation at a later date either in-office or will return to the facility to do so.

No deficiencies were cited during today's inspection.

Exit interview conducted with Administrator whose signature on form confirms receipt.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2025

LIC809 (FAS) - (06/04)

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