286803041-10-11-2021-21-AS-CFGS-C7PMGA-20211011093536

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 10/07/2021
Date Signed: 10/11/2021 09:37:19 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, 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: 5	DATE:	10/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ali Dastghab - Administrator		TIME COMPLETED:	03:45 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	Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. & Non-Compliance Infection Control inspection to this facility and was welcome by staff Linda L. & Bella R. Staff contacted lead staff Ray G. who wasn’t able to attend visit. Licensee Jocelyn Ricasta was contacted as well as pending administrator Ali Dastghab. Administrator Ali Dastghab arrived during the visit. Facility has 5 residents with no residents under hospice care. Facility has no activities for residents during the day. LPA arrived at the facility and had her temperature checked and logged into visitor’s binder. During facility tour on 10/7/2021 with staff Bella R., facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 07/2021 at the time of the visit. Sample of Smoke & Carbon monoxide detectors test were found operational during visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator was properly stored as per regulations on this day at the time of the visit. Food is available for residents any time of the day. Toxins are stored in a locked hallway closet and under sink in food storage area. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility hot water temperatures on residents' faucets measured between 113.7- and 114.4 - degrees F within Title 22 acceptable regulations of 105 to 120 degrees F. During this visit LPA learned that facility has admitted a resident R1 w/ a diagnostic of DM2 who needs glucose testing daily. In addition, resident R1 has an LIC 602 dated 9/30/2020 which state that resident R1 is no able to administer insulin shots or glucose testing. Per staff, facility is assisting resident R1 on glucose testing daily. (LIC 809-D) Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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: 10/07/2021

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Posters have not been placed at facility. Entrance has hand sanitizer and other items designated for visitors and staff before coming into work. Facility has PPE supply stored in hallway storage. Facility has hired staff and admitted new residents since COVID-19.

Residents’ medications are stored and locked kitchen cabinet. Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. Facility understands that unvaccinated staff must be tested once a week if PCR and vaccinated staff doesn’t need to be tested at this time if staff is able to show proof of vaccination which copy of vaccination card must be kept on facility file for staff at this time according with PIN 21-32-ASC & PIN 21-32.1-ASC: UPDATED FACILITY STAFF TESTING AND MASKING GUIDANCE FOR CORONAVIRUS DISEASE 2019 (COVID-19)

In addition, facility allowing visitors in the facility. Residents have also available telephone calls when contacting with family members and others. Staff had all PPE training required on file and are working towards obtaining N-95 fit testing. LPA had a discussion with administrator regarding visitation guidelines per PIN 21-40-ASC: UPDATED STATEWIDE VISITATION WAIVER, AND TESTING AND VACCINATION VERIFICATION GUIDANCE FOR VISITORS RELATED TO CORONAVIRUS DISEASE 2019 (COVID-19)

LPAs advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted with the last one on 8/1/2021.

Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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: 10/07/2021

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There has been a change of administrator in the facility Department is requesting the following pending documentation to be submitted by October 14, 2021:

LIC 200 (original - must be mailed or delivered to the Regional Office)

Appeal of Rights Given.

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.

Department is requesting facility to update and submit the following documents to CCLD by 10/14/2021:

LIC 308 Designated Administrator
LIC 500
LIC 610 Emergency Disaster Plan
Copy of Deed or Lease agreement
Copy of Job Description/Personnel Policies

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

Page: 5 of 9

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: 10/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87628(a)

Diabetes

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview,& record review, the licensee did not comply with the section cited above in 1outof1 resident which poses an immediate health,safety or personal rights risk to persons in care.Resident R1 has LIC 602 dated 9/30/20 stating resident R1 is no able to administer insulinshots or glucose testing.Per staff,facility&family member is assisting resident R1 on glucose testing daily.
	POC Due Date: 10/08/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that to accept & retain resident with diabetes if not able to perform his/her own glucose testing and/or able to administer injections that a skilled professional will be available to perform these tasks as needed. Administrator/Licensee to submit self certification that staff or family member are conducting testing & plan for glucose testing by POC due date.

Section Cited

Care of Persons with Dementia


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

Page: 7 of 9

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: 10/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

(c)licensees who accept and retain residents with dementia should be responsible for ensuring the following:(5) each resident with dementia shall have an annual medical assessment as specified in Section 87458, medical assessment, and a reappraisal done at least annually... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care. Resident R1 has an assessment which dated 9/30/2020 w/ a diagnostic of dementia.
	POC Due Date: 10/21/2021
	Plan of Correction
1 2 3 4	Licensee to ensure that all residents with a diagnostic of dementia have an annual medical assessment done at least annually. Facility to submit a new LIC 602 for resident R1 by POC due date of 10/21/2021 in order to clear this citation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

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