286801359-4-29-2025-21-AS-JFLO-DG7RVU-20250429132208

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286801359
Report Date: 04/29/2025
Date Signed: 04/29/2025 01:22:22 PM

Document Has Been Signed on 04/29/2025 01:22 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:	NAPA VALLEY SUPPORT SERVICES - BROWN STREET		FACILITY NUMBER:	286801359
ADMINISTRATOR/ DIRECTOR:	EMMY BENNETT		FACILITY TYPE:	775
ADDRESS:	2225 BROWN ST., STE. 102		TELEPHONE:	(707) 255-8523
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY: 30		CENSUS: 29	DATE:	04/29/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Emmy Bennett, Director		TIME VISIT/ INSPECTION COMPLETED:	01:30 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 9:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Required - 1 Year inspection and met with Emmy Bennett, Director. Facility provides mostly in-person services, Monday through Friday from 8:00 AM - 2:00 PM. The facility offers Zoom participation for clients who wish to attend from home or are away on vacation. Facility does not offer transportation services to and from their day program, but they do have two (2) vehicles used for facility outings. Facility is vendorized with North Bay Regional Center (NBRC) and all the clients have a service coordinator. At approximately 10:30 AM LPA initiated tour of the facility with Director and observed the following: facility was a comfortable temperature and the required signage was posted. Exits were observed unobstructed and chemicals and other items which could pose a risk to clients in care were observed stored in locked cabinets and closets. Director agrees to ensure that Lysol sprays used in bathrooms remain inaccessible to clients at all times to remain in compliance with regulation. Hygiene and paper products were available to clients. Water temperatures in facility bathrooms tested within the allowable range of 105-120 degrees Fahrenheit per Title XXII regulations. LPA observed multiple first aid kits, PPE, emergency supplies, and incontinent care products. Fire extinguishers were both observed fully charged and last inspected 04/2025. Facility is hardwired with a sprinkler system which was last inspected 04/2025. Smoke and carbon monoxide detectors were tested and operational during inspection. Facility conducts emergency disaster drills monthly with the last drill conducted 04/2025. Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

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: NAPA VALLEY SUPPORT SERVICES - BROWN STREET	FACILITY NUMBER: 286801359
	VISIT DATE: 04/29/2025

NARRATIVE

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continued from LIC809...

LPA observed all clients engaged in art projects during inspection. Facility focuses on the arts, and the clients have a store front in the facility and participate in bi-monthly farmer's markets where they sell their artwork (tie die clothing, cards, holiday decor, glassware, and more). The proceeds are split between the facility to purchase supplies and the clients. Facility also has several computers for client use. Facility director states that clients participate in scheduled activities weekly on M-W-Th such as serving lunches with Meals on Wheels and at the local senior center and cleaning toys at the local library. Facility does not manage medications or P&I cash resources.

At approximately 11:30 AM, LPA initiated file review of five (5) client files. All client files reviewed had all the required documentation per regulation. Facility does not have staff files on site. They are kept at their Administrative office, (see LIC809D). Facility does have proof of current first aid and CPR training for staff on site.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:

LIC610 - Emergency plan (updated)

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, 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.

Exit interview conducted with Director, whose signature on form confirms receipt of documents. Appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/29/2025 01:22 PM - It Cannot Be Edited

Created By: Julie Florio On 04/29/2025 at 01:04 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAPA VALLEY SUPPORT SERVICES - BROWN STREET	FACILITY NUMBER: 286801359
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

82066(c)

Personnel Records

(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having personnel files maintained on site and readily available for inspection by the Department upon request which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/30/2025
	Plan of Correction
1 2 3 4	Licensee to submit a self-certification that "all staff files are now readily available to licensing personnel upon request" to CCL by POC due date 05/30/2025.

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.

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Julie Florio
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025

LIC809 (FAS) - (06/04)

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