286801534-2-29-2024-21-AS-BMOS-D32NWV-20240304095011

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286801534
Report Date: 02/28/2024
Date Signed: 02/29/2024 10:51:49 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240213125456

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:	02/28/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Magno “June” Privado & Gerry Ofiaza Staff		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff left resident in soiled diaper

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above complaint allegation and met with staff Magno “June” Privado & Gerry Ofiaza. Staff called Licensee/Admin Roa Francisco who authorized staff to sign and informed LPA requested documents (602 for R1 & Lib Ins) are not available.

Staff left resident in soiled diaper – Complaint alleges resident (R1) was in facility approximately 24 hours and did not have incontinent care needs met, left in soiled undergarments. LPA confirmed through staff interview R1 was in facility approximately 24 hours and was not provided incontinence care or assistance to the bathroom. LPA obtained police report regarding incident which supports R1’s incontinent care was not met. Additionally, per interview, staff was not provided a care plan and or Physicians Report by Licensee/Administrator.

Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240213125456

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/28/2024

NARRATIVE

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Based on LPA’s interviews and Police Report obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Appeal Rights Given

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240213125456

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/29/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator to provide staff training on incontinence care to meet the needs of residents. Training schedule of type due to CCL by 2/29/24.
	8 9 10 11 12 13 14	Based on LPA interview’s and Police Report, facility did not provide incontinence care for resident. Which is an immediate health and safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	Sufficient training for staff on incontinence care, signed & dated by staff due to CCL by COB 3/07/2024.
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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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC9099 (FAS) - (06/04)

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