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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801534
Report Date: 03/19/2024
Date Signed: 03/19/2024 09:43:46 AM


Document Has Been Signed on 03/19/2024 09:43 AM - 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: 6DATE:
03/19/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Teresa Gonzales, staffTIME COMPLETED:
09:45 AM
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Licensing Program Analyst (LPA) Hansen arrived unannounced on this day 3/19/2024 to conduct a Case Management visit -Plan of Corrections (POC) visit. Staff called Licensee/Admin Roa Francisco who authorized staff to sign documents for today's visit.

During complaint 21-AS-20240213125456 visit dated 2/28/2024 LPA conducted a case management visit for deficiencies found during complaint investigation. While conducting complaint investigation it was revealed that the licensee did not have on file required documentation of a medical assessment for resident (R1), signed by a physician, made within the last year, prior to admission. A citation was given for regulation 87458(a) Medical Assessment: Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file documentation of a medical assessment, signed by a physician, made within the last year.
Licensee was also cited for not submitting required incident report (SIR 624) for R1 when taken out of the facility by ambulance to the hospital on 1/18/2024. Per regulation 87211(a), licensee shall submit a report to licensing agency within 7 days of an occurrence of any incident that threatens the welfare, safety, or health of any resident.

Licensee has not corrected the POC’s by the due date. Civil Penalties issued.

Civil penalties are being assessed today in the amount of $1,200.00 X 2 = ($2,400.) for failure to correct POC’s and will continue to run at $100.00 per day per citation until corrected.

Continue on Lic 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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: 03/19/2024
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Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. 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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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