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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803041
Report Date: 03/08/2022
Date Signed: 03/09/2022 08:46:09 AM


Document Has Been Signed on 03/09/2022 08:46 AM - 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: DATE:
03/08/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Jocelyn Ricosta; Ali DastgheibTIME COMPLETED:
02:12 PM
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At approximately 1:30PM, Licensing Program Manager (LPM's) Bethany Moellers and Kimberley Mota and Licensing Program Analyst's (LPA's) Dominic Tobola and Chris Arnhold, conducted a virtual Office visit with licensee Jocelyn Ricosta and Administrator Ali Dastgheib. The purpose of this meeting is to discuss with Licensee and Administrator, the Non-Compliance plan (NCC) and the lack of compliance. On 02/16/2022, the department conducted a quarterly NCC visit and learned the Licensee accepted a new resident that was currently on Hospice. Facility did not submit a request for a Hospice Exception. This action violates the NCC plan established during the NCC meeting held on 04/20/2021, at which time the facility Hospice waiver was revoked. Licensee was informed the non-compliance of the NCC plan, signed 04/20/2021, will be raised to the Departments enforcement attorney for review.

Original signature on file. A copy of this report was emailed to Licensee.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2022
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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