286801534-3-10-2022-21-AS-CFES-CCDULS-20220310144112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286801534
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:41:22 PM

Document Has Been Signed on 03/10/2022 02:41 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:	WINE COUNTRY SENIOR'S VILLA		FACILITY NUMBER:	286801534
ADMINISTRATOR:	CRUZ, TERRY & ROA, F		FACILITY TYPE:	740
ADDRESS:	3552 JEFFERSON ST.		TELEPHONE:	(707) 226-3055
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 5	DATE:	03/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:47 PM
MET WITH:	Administrator, Francisco (Kits) Roa		TIME COMPLETED:	02:50 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 12:40PM, Licensing Program Analysts (LPAs) Willis and Felias, and LPM Mota, arrived unannounced to conduct an Annual Inspection visit and was greeted by Staff Member, Gerry Ofiaza. The inspection is focused on the Infection Control procedures and practices of this facility. Administrator, Francisco (Kits) Roa arrived later during the visit. Upon arrival at the facility, LPAs had their temperatures checked and logged. LPAs conducted a walk-through of the facility and observed the following: COVID-19 signs were observed at the entry way and throughout the facility. Hand-washing signs were observed in the bathrooms and at sinks. One staff member was observed not wearing a mask but put one on when LPAs requested. The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Administrator and LPAs discussed two current staff that are fingerprinted but not associated to facility. Administrator has run into technical difficulties in their attempts to send to CCL. Administrator provided association paperwork today. LPAs will process associations once back in the office and will send information regarding the Guardian. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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: WINE COUNTRY SENIOR'S VILLA	FACILITY NUMBER: 286801534
	VISIT DATE: 03/10/2022

NARRATIVE

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Continued from LIC-809.

All staff have received training on infection control and have been N95 Fit-Tested. Facility has a cleaning and disinfecting schedule that occurs twice per day. Facility has at least a 30-day supply of Personal Protective Equipment (PPE) and medication for clients. Staff and Residents are screened daily for COVID-19 symptoms and it is logged into facility binders.

Upon observation of the facility backyard, LPAs observed the following: the backyard exit gate was hard to unlatch, two mattresses were leaning against the side of the facility, and the concrete pathway was coming up. LPAs discussed with Administrator on fixing these observations to ensure that a safe evacuation could occur if needed. Per conversation with Administrator, the mattresses are scheduled to be picked up by the end of this month.

LPAs observed personal medication and incontinence schedules for residents written in a common area space. Per conversation with Administrator, care staff write down information so they do not forget. LPAs and Administrator discussed writing down the information somewhere else that is not in a public space.

Fire Extinguishers were last serviced September 2021. Fire alarm system and sprinklers was last serviced November 2021.

No Deficiencies were cited during this inspection.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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