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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801534
Report Date: 02/28/2024
Date Signed: 02/28/2024 09:54:24 AM

Document Has Been Signed on 02/28/2024 09:54 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: 5DATE:
02/28/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: Magno “June” Privado & Gerry Ofiaza StaffTIME COMPLETED:
10:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen was at facility delivering findings of complaint investigation and conducted a case management for a separate deficiency that was found during complaint investigation. LPA met with Magno “June” Privado & Gerry Ofiaza Staff. Staff contacted Licensee/Admin by phone, LPA spoke with, who authorized staff to sign documents and informed LPA requested documents (602 for R1 & Lib Ins) are not available.

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. The department is issuing a citation of regulation 87458(a) Medical Assessment. Licensee also did not submit required incident report 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.

On 1/4/2024 LPA conducted annual inspection of facility and requested documents/current liability insurance. Community Care Licensing (CCL) has yet to receive document and is requesting Licensee to submit current liability insurance by Close of Business (COB) on 3/6/2024.

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..

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2024 09:54 AM - It Cannot Be Edited


Created By: Shannan Hansen On 02/28/2024 at 08:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
03/07/2024
Section Cited
CCR
87458(a)

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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. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.
This requirement is not met as evidenced by:
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Licensee to submit written statement agreeing to obtained all required documents for residents prior to admissions for compliance. POC due date 3/7/2024.
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Based on LPA record review and observation, facility did not obtain & or keep on file resident R1’s medical assessment or physician’s report, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
03/07/2024
Section Cited
CCR87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements:(a) Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by:
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- Licensee to provide training to all care staff reviewing the Regulation: 87211 Reporting Requirements and how to properly fill out the LIC 624 form. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 03/07/2024.
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Based on interviews conducted, and documents obtained, the Licensee did not comply with the section cited above and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.
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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
LICENSING EVALUATOR NAME:Shannan Hansen
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


LIC809 (FAS) - (06/04)
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