286801095-9-17-2021-21-AS-CFGS-C6XKE2-20210917074937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286801095
Report Date: 09/16/2021
Date Signed: 09/17/2021 07:49:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	BERKSHIRE, THE		FACILITY NUMBER:	286801095
ADMINISTRATOR:	STONAWSKI, A. & SEMPLE, A.		FACILITY TYPE:	740
ADDRESS:	2300 BROWN STREET		TELEPHONE:	(707) 252-9037
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	72	CENSUS: 11	DATE:	09/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Lia Miller - Ass. Administrator		TIME COMPLETED:	02:15 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) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Ass. Administrator Lia Miller. Facility has 13 residents present with 4 residents under Hospice care. Facility offers activities ball bouncing, bingo, reading, current events, and etc. During facility tour on 9/16/2021 with Ass Administrator Lia Miller facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was last charged on 4/2021. Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. Facility has a smoke detector system that is connected, and last inspection occurred on 8/5/2021 & 9/10/2021. 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 on this day at the time of the visit. Dangerous items were stored inaccessible to residents in locked in a cleaning supply closet. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Facility understands that hot water temperatures must measure within Title 22 acceptable regulations of 105 to 120 degrees F. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed at facility and entrance has a table with hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in the facility storage room. Facility has hired and admitted new residents and staff since COVID-19. Residents medications are stored and locked in a locked medication room. Facility has a 30-day supply of medication for residents. Residents are not wearing masks inside the facility, however; staff stated that they are sometimes able to wear masks when going on outings. All staff had masks on during this visit. Continued LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BERKSHIRE, THE	FACILITY NUMBER: 286801095
	VISIT DATE: 09/16/2021

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In addition, facility has a designated area for visitors which are being allowed for visits. Residents also have available video and telephone calls when contacting with family members and others. Staff had all PPE training required on file and facility is working towards obtaining N-95 fit testing.

In addition, LPA advised facility to contact local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32 & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19). In addition, LPA had a discussion with administrator regarding visitation guidelines per PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19).

LPAs reviewed Licensing Information System (LIS) with staff who stated that is correct and updated at this time. Disaster Drills had been conducted quarterly last being done 7/2021.

There were no deficiencies cited at this time.

Department is requesting facility to submit to CCL the following updated documents by 9/23/2021:

LIC 309 Administrative Organization
LIC 308 Designation of Facility Responsability
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
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC809 (FAS) - (06/04)

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