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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801534
Report Date: 03/28/2024
Date Signed: 03/28/2024 09:56:10 AM


Document Has Been Signed on 03/28/2024 09:56 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:
03/28/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gerry Ofiaza, StaffTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen arrived unannounced on this day 3/28/2024 to conduct a Case Management -Plan of Corrections (POC) visit. Staff called Licensee/Admin Roa Francisco who authorized staff to sign documents for today's visit.

LPA entered facility today (3/28/2024) at approximately 9:00am and was informed there is a new staff (S1). LPA contacted Community Care Licensing (CCL) and was informed this individual was background cleared but not associated to the facility as of today. LPA is citing per regulation 87355(c) Criminal Record Clearance (see LIC809-D). Immediate Civil Penalties for $100.00

LPA observed 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. 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), Reporting requirements.

On 3/19/2024 LPA conducted a case management-POC visit to facility assessing civil penalties of $2,400 for failure to correct the 2 CP’s above and informed will continue to run at $100 per day per citation until corrected.

On 2/28/2024 LPA delivered findings for complaint 21-AS-20240213125456. Complaint was substantiated and facility was cited on 2/28/2024 for resident (R1) not having incontinent care needs met and left in soiled undergarments for approximately 24 hours. Plan of correction due date was 2/29/2024, licensee has not submitted required documentation to clear citation, LPA was unable to conduct visit giving civil penalties.
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: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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: 03/28/2024
NARRATIVE
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Continued from LIC 809

On 3/19/2024 LPA cited facility again for regulation 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. As of today, 3/28/2024 facility has yet to correct citation and is being assessed civil penalties.
Licensee has not corrected the POC’s by the due date. Civil Penalties issued.

Civil penalties for 87355(c) BG $100.00

Civil penalties for 87458(a) & 87211(a) are being assessed today for an additional $900.00 X 2 = ($1,800.) for failure to correct POC’s and will continue to run at $100.00 per day per citation until corrected.

& Civil penalties for 87411 (a) are being assessed today in the amount of $800.00 for failure to correct POC and will continue to run at $100.00 per day until corrected.

Total Civil penalties for today’s visit are $100.00 + $1,800 + $800 = $2,700.00

Regional office will be requesting an office meeting to discuss non-compliance of clearing POCs. Continued non-compliance may result in administrative action.

The following deficiencies were observed (see LIC 809D) 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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/28/2024 09:56 AM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2024
Section Cited
CCR
87355(c)

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87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: This requirement was not met as evidenced by: LPAs interviews, and review of records, and

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Licensee to ensure all staff are crminal record cleared and associated to the facility as required ..
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running a fingerprint record search in the Guardian website. S1 is not associated to the facility as required. This is an immedicate health & safety and/or personal rights risk to residents in care. Civil Penatly assessed for $100.-see LIC421BG.
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Licensee to submit all required documents for individuals to be associated per regulations. Plan of correction is due 3/29/24.

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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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