286803041-4-27-2021-21-AS-AELT-C2GTRE-20210427145727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 04/20/2021
Date Signed: 04/27/2021 02:59:16 PM

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, LLC		FACILITY NUMBER:	286803041
ADMINISTRATOR:	RICASTA, JOCELYN		FACILITY TYPE:	740
ADDRESS:	1161 LA HOMA DRIVE		TELEPHONE:	(707) 252-7426
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 4	DATE:	04/20/2021
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jocelyn Ricasta		TIME COMPLETED:	02:00 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	Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst (LPA) Angela Elliott and Licensing Program Analyst Shannan Hansen made contact on this date, via tele-visit, with Licensee Jocelyn Ricasta for the purpose of reviewing issues for Non-Compliance Conference. It is being conducted by tele-visit phone due to COVID - 19 precautions. LPA and LPM made subsequent phone call to deliver finalized reports with Licensee, which were e-mailed for signature. Due to areas of concern identified by the Department, Non Compliance Conference was held. Verbal commitment from Licensee/Manager was received for Non-Compliance plan during conference. Agreement to receive Technical Support assistance was agreed upon. Non Compliance Conference was held to discuss areas of concern including: Reporting Requirements Incidental Medical and Dental Care Observation of the Resident Personal Rights. Criminal Record Clearance Personnel & Resident Records. POCs not resolved by agreed upon POC date, currently outstanding.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LA HOMA GUEST HOME, LLC	FACILITY NUMBER: 286803041
	VISIT DATE: 04/20/2021

NARRATIVE

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Three Complaints alleging similar concerns including but not limited to, personal rights, criminal record clearance, not meeting resident care needs, seeking timely medical attention, and reporting requirements.

Licensee agreed to TSP service. Compliance Plan will be for two years and facility Hospice Waiver for two has been rescinded. Licensee agreed to send reporting documentation form SOC341 and police correspondence related to R1 leaving facility on 12/22/2020 as well as R1's death report.

Community Care Licensing will mail a copy of License reflecting updated Hospice status to Licensee today.

No deficiencies cited during the Non-Compliance Conference

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC809 (FAS) - (06/04)

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