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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803264
Report Date: 04/07/2021
Date Signed: 04/07/2021 03:23:31 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:NAZARETH ROSE GARDEN OF NAPAFACILITY NUMBER:
286803264
ADMINISTRATOR:GOCO, MARISOLFACILITY TYPE:
740
ADDRESS:903 SARATOGA DRIVETELEPHONE:
(707) 252-7488
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:44CENSUS: 26DATE:
04/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Marisol GocoTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elliott spoke with Marisol Goco, Executive Director over the phone to review incident occurring on 11/19/2019. It was reviewed over the phone due to COVID 19 precautions.

LPA conducted on site case management inspection on 1/14/2020 to follow up on incident report received by Community Care Licensing (CCL) on 11/20/2019 reporting a fire in the building. Today's case management inspection is to conduct subsequent follow-up after obtaining additional documentation. On 11/19/2019 around 1:30 AM facility fire panel and fire alarm was activated. Bay Alarm contacted the facility S1 on shift was unaware how to operate the fire panel. Bay Alarm contacted Napa Fire Department, staff began doing rounds at the facility. Upon arrival of Napa Fire Department it was determined staff had not evacuated building. Smoke was in the hallway of rooms 11-15. Based on report Napa County Fire Dept requested S2 open room 15 due to it being locked. It was discovered R1 was located in bed in a smoke filled room. R1 was transported to the hospital for evaluation and returned to the facility the same day. Bay Alarm Service notice dated 11/19/2019 reflects "Wire for smoke was burned and was replaced. Replaced smoke detector in Room 15."

Mass Casualty Plan and Emergency Care section in facility plan of operation outlines 1) All residents with dementia will be assisted and supervised during evacuation. 2) Resident will be removed from the danger zone area and staff will count for their whereabouts at all times. Facility staff failed to supervise and evacuate R1 from the danger zone area.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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: NAZARETH ROSE GARDEN OF NAPA
FACILITY NUMBER: 286803264
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2021
Section Cited

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87212 Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (1) Designation of administrative authority and staff assignments.(2) Plan for evacuation including:(A) Fire safety plan. This requirement was not met as evidenced by:
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Based on LPA observation, interview and record review, S1 didn't know how to operate fire alarm panel . S2 checked R1's bedroom, saw smoke, didn't report it and R1 was found locked in their smoke filled room. This poses an immediate risk to the health, safety and personal rights to residents in care.
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trained in updated Emergency Disaster Plan and 2) submit documentation from the Fire Department indicating fire damage has been repaired and is no longer a risk to the health and safety of residents by POC due date of 4/12/2021.

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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: 04/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2021
LIC809 (FAS) - (06/04)
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