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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 03/05/2021
Date Signed: 03/05/2021 11:17:55 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LA HOMA GUEST HOME, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:RICASTA, JOCELYNFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 5DATE:
03/05/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jocelyn RicastaTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Chris Arnhold conducted this case management visit in regards to violations found while reviewing documents related to a complaint investigation. LPA met with Jocelyn Ricasta via telephone, due to Covid-19 precautions.
LPA reviewed staff training records and found staff did not receive the required number of ongoing training as required by regulation. The records indicated only 2 staff received training in the amount of 10 and 11 hours for each. Based on interviews conducted and a review of records, administrator did not administer medication as directed by physician. Physician orders directed the use of a PRN medication as 1 tablet every 4 hours as needed. Interviews indicated staff only gave 1/2 tablet. A review of records indicate resident is not able to communicate needs and is not able to manage their own medication. The only PRN documentation was a PRN administration record that showed 1 tab given every 9 hours. The section for the result of the PRN only had a line through, continuing the "Pain Better" comment for each dose. There were no documents in the file to indicate the facility was in contact with the physician regarding the administration of the PRN, as required by regulation when a resident is not able to communicate their needs.
A copy of the Health and Safety code section 1569.625, Staff Training; legislative findings; contents and 87465 Incidental Medical and Dental Care was provided to Licensee for review.

The Department will be scheduling a meeting with Licensee to discuss areas of concern.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Jocelyn Ricasta and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2021
Section Cited

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1569.625 Staff training; legislative findings; contents: (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly...This training shall consist
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of 40 hours of training. This requirement is not met as evidenced by: Based on records review, Licensee did not provide staff the required number of training hours. This poses an immediate safety risk to residents in care.
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Type A
03/06/2021
Section Cited

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87465(d)Incidental Medical and Dental Care- If the resident is unable to determine his/her own need...and is unable to communicate his/her symptoms clearly...(2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record.
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This requirement is not met as evidenced by: Based on records review, Licensee did not document communication with physician regarding the administration of the PRN. This poses an immediate health and safety risk to residents in care.
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date of 3/6/2021, Training to be completed by 04/02/2021. Training certificates to be submitted to CCL.
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) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2021
LIC809 (FAS) - (06/04)
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