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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801534
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:17:10 PM

Document Has Been Signed on 01/26/2023 01:17 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 VILLAFACILITY NUMBER:
286801534
ADMINISTRATOR:CRUZ, TERRY & ROA, FFACILITY TYPE:
740
ADDRESS:3552 JEFFERSON ST.TELEPHONE:
(707) 226-3055
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 3DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Staff, Gerry OfiazaTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 01/26/2023 to conduct a required 1 - year inspection. This inspection was focused on the infection control practices and procedures of this care facility. Administrator Francisco Roa was not available for the inspection but was notified over the phone. LPA conducted inspection with staff, Gerry Ofiaza

LPA toured building and grounds which were clean and in good repair. Exits and walkways were clear from obstructions. COVID postings and screening materials were present at the front entrance. High touch surface areas are disinfected daily. Bathrooms had necessary grab bars and nonskid flooring. Facility has a sufficient amount of perishable and nonperishable food. Sufficient personal protective equipment was available to support a resident in isolation. Toxins were locked and secured. Medications were locked and secured.

LPA observed one fire extinguisher located near the kitchen. Tag indicated it was last charged on 09/22/2021. Fire safety compliance report posted from Napa Fire Department's last inspection was from 10/8/2019. Last emergency evacuation drill was performed 11/10/2019 per posting. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.


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 610 Emergency Disaster Plan, LIC 500 Personnel Report, LIC 9020 Client Roster, Evidence of Liability Insurance, Current Admin Certificate

Exit interview conducted with staff. Report emailed to administrator before leaving the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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 01/26/2023 01:17 PM - It Cannot Be Edited


Created By: Erik Gonzalez Campos On 01/26/2023 at 12:34 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: WINE COUNTRY SENIOR'S VILLA
FACILITY NUMBER: 286801534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety - All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the only fire extinguisher observed was last serviced 09/22/2021 which poses a potential health and safety risk to residents in care.
POC Due Date: 02/03/2023
Plan of Correction
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Licensee to have fire extinguishers serviced, to submit current fire safety compliance report provided by Napa Fire Department, and to submit schedule of planned disaster drills with staff by POC due date 02/03/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2