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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 02/16/2022
Date Signed: 02/16/2022 01:19:05 PM


Document Has Been Signed on 02/16/2022 01:19 PM - 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:LA HOMA GUEST HOME, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:DASTGHEIB, ALIFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
02/16/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Ali DastgheibTIME COMPLETED:
01:35 PM
NARRATIVE
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At approximately 8:30AM, Licensing Program Analysts (LPAs) Arnhold and Felias arrived unannounced to conduct a Case Management Legal/Non-Compliance visit. LPAs were greeted by Staff Member Ray G. Upon arrival, LPAs observed visitation signs at the entry way and temperatures were checked. Administrator, Ali Dastgheib, arrived later during the visit. Facility has 6 residents with 2 residents under Hospice Care. Facility Hospice Care Waiver was revoked on 4/20/2021 as per a Non-Compliance conference (NCC) on that date. Facility failed to request exceptions as required in the Non-Compliance plan. LPAs toured the building which was found to be clean and in good repair. Toxins were secure and not accessible to residents. LPAs observed unsecured medication on the kitchen table accessible to residents. Staff immediately secured medication. Administrator is working to change medication storage to ensure medication is always secure and inaccessible to residents.

LPAs reviewed 6 of 6 Resident files. R1 did not have a hospice care plan on file. 6 of 6 residents' physician reports and appraisals were up to date. All staff present at the facility were fingerprinted and associated.

LPAs provided Administrator with a copy of the NCC plan for review.

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 Administrator and Appeal rights were given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
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 02/16/2022 01:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2022
Section Cited

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87465 Incidental Medical and Dental Care:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
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Based on observation, LPAs observed unattended medication on the kitchen table that was assessible to residents. This poses an immediate health and safety risk to residents in care.
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Type A
02/17/2022
Section Cited

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87632 Hospice Care Waiver: (a) In order to accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement is not met as evidenced by: Based on NCC dated 4/20/2021, the Department revoked the
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facility's hospice care waiver. Facilty did not request exception for residents R1 and R6 per NCC plan. This poses an immediate 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/16/2022 01:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited

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87633 Hospice Care of Terminally Ill Residents: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary...and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement is not met as evidenced by:
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Based on record review, Licensee did not ensure R1 had a hospice care plan in their file. 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3