<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801534
Report Date: 04/10/2024
Date Signed: 04/10/2024 03:48:10 PM


Document Has Been Signed on 04/10/2024 03:48 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: 6DATE:
04/10/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Licensee/Administrator Roa "Kit" FranciscoTIME COMPLETED:
04:00 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
Licensing Program Manager Bethany Moellers, Licensing Program Analyst Shannan Hansen and Licensing Program Analyst Julie Florio conducted an informal office meeting, and met with Licensee/Administrator Roa "Kit" Francisco.

This informal meeting is being conducted to discuss concerns identified in regards to the operation of this facility, including but not limited to:
  • Clearing POC's timely

  • Current fire clearance is for only 6 non-ambulatory no bedridden (602- regarding complaint 21-AS-20240213125456 was bedridden). Licensee agrees to review LIC602's for all residents in care to insure ambulatory status is in compliance with fire clearance.

  • Facility not providing requested Liability Insurance, licensee informed and provided email to insurance agent in the attempt to obtain liability insurance. Citation issued on 3/19/2024 with a POC due date of 4/10/2024. Licensee was advised to follow up with insurance agent and to request an extension of POC date if needed.

  • Administrators presences in the facility - requesting updated LIC 500 by 4/17/2024

  • Change of Ownership (CHOW), licensee was provided regulation and procedures regarding the change of ownership process. Licensee understands responsibility until application is received at the department and new license issued.

No deficiencies cited during today’s informal office visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1