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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 09:59:22 AM


Document Has Been Signed on 03/19/2024 09:59 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: DATE:
03/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Teresa Gonzales, StaffTIME COMPLETED:
10:15 AM
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Licensing Program Analyst (LPA) Hansen was conducting Plan of Correction visit with facility and conducted a Case Management visit. Staff called Licensee/Admin Roa Francisco who authorized staff Teresa Gonzales to sign documents for today's visit.

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. Today LPA is citing 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.

On 1/4/2024 LPA conducted annual inspection of facility and requested documents/current liability insurance. On 2/28/24 case management LPA requested copy of liability insurance to be submitted by 3/6/2024. Community Care Licensing (CCL) has yet to receive document and is citing facility for not submitting required documents. Per Health & Safety Code # 1569.605 all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

Licensee indicated Insurance documents will be submitted to CCL by 4/10/2024

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
NARRATIVE
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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: 03/19/2024
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)
Page: 2 of 3
Document Has Been Signed on 03/19/2024 09:59 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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/20/2024
Section Cited
CCR
87411(a)

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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:
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POC: Licensee/Administrator to provide staff training on incontinence care to meet the needs of residents. Training schedule type due to CCL by 3/20/24.
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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.
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Sufficient training for staff on incontinence care, signed & dated by staff due to CCL by COB 3/27/2024.
Request Denied
Type B
04/10/2024
Section Cited
HSC1569.605

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H&S 1569.605 - Liability Insurance: Based on review and interview the licensee did not comply with the section cited above 1 of 1 facility liability insurance which poses a potential health, safety or personal rights risk to persons in care.
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Licensee understands that all facilities licensed by the Department must have liability insurance according to requirements to stay in compliance. Licensee to obtain liability insurance in compliance with H&S Code # 1569.605 ....
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and submit a copy to the CCLD by due date of 04/10/2024.
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: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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