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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 08/23/2021
Date Signed: 08/23/2021 04:05:59 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, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:RICASTA, JOCELYNFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 4DATE:
08/23/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jocelyn RicasataTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Elliott conducted a case management- Legal/Non-compliance inspection, on 8/23/2021, at approximately 10:00 AM. LPA met with Administrator/Licensee Jocelyn Ricasata. This continuation inspection is being completed to ensure compliance with Non-Compliance Conference dated 4/20/2021.

There are 4 residents in care, none are on Hospice. LPA reviewed 4 resident records. R1 did not have a care plan and R2 and R3's care plan were not signed by the responsible party. LPA reviewed resident medications. Four residents did not have medications available, and medication counts did not match Central Stored Medication and Destruction Record for four residents. Medications were not stored in the original container for 3 out of 4 residents and 2 out of four residents did not have medications stored per regulation. Additional time will be needed to continue this inspection.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and 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. Appeal rights given.

(See LIC 809-D)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
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 3
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: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2021
Section Cited

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87465(c)Incidental Medical and Dental Care....shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
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Based on LPA observation, interview and record review, Licensee did not ensure medications were not available for 4 our of 4 residents. This poses an immediate risk to the health, safety and personal rights of residents in care.
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Type A
08/24/2021
Section Cited

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87465 Incidental Medical & Dental Care:(h) The following requirements shall apply to medications which are centrally stored:
(5) Each resident's medication shall be stored in its originally received container. This requirement is not met as evidenced by:
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Based on LPA observation, interview and record review, Licensee did not ensure that medication were stored in original container for 3 of 4 residents which posses a potential health 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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 08/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/24/2021
Section Cited

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87465 Incidental Medical and Dental Care (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. This requirement was not met as evidenced by:
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Based on LPAs observation, interview and record review facility did not ensure medication for 2 out of 2 residents was stored properly. This poses a potential risk to the health safety and personal rights of residents in care.
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Type B
09/06/2021
Section Cited

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87463 Reappraisals-(c)The licensee shall arrange a meeting with the resident, the resident’s representative...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidenced by:
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Based on LPA observation, interview and record review, Licensee did not ensure there were complete care plans for 3 out of 4 residents. This poses a potential risk to the health, safety and personal rights 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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3