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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803264
Report Date: 05/18/2021
Date Signed: 05/18/2021 10:49:13 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: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: 27DATE:
05/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Minerva Villegas/Marisol GocoTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Angela Elliott conducted an unannounced Annual Required – 1 year Infection Control inspection to this facility and met with Minerva Villegas, Wellness Director, Executive Director Marisol Goco arrived later. Residents were observed in the living room watching TV and dining room eating breakfast. Other residents were resting in their rooms.

LPA arrived at the facility and had temperature scanned. Visitor- log and questionnaire document were completed. Visitor, staff and resident logs were reviewed. During facility tour the facility was found to be clean and at a comfortable temperature with all exits free from obstruction. There was one entry point for the facility. Facility has submitted a mitigation program plan that has been approved. Postings pertaining to COVID-19 were throughout the facility. Entrance has a small table with hand sanitizer and other items designated for visitors and staff before coming into work. Personal Protective Equipment (PPE) is stored in cabinets throughout the facility. Supplies were adequate for 30 days, and facility has a vendor for ordering supplies. Supplies are monitored by the Wellness Director. LPA discussed PPE supplies could also be picked up at Community Care Licensing (CCL) Regional Office. Emergency Disaster Plan update was posted while LPA was at the facility. Resident emergency contact information has been updated. Residents’ medications are stored in a locked medication cart and secured in the Medication Room. Facility has a 30-day supply of medication for residents. Designated visiting areas include facility Sun Room, resident rooms and outdoor courtyard. Housekeeping cleans the facility twice a day and focuses on high touch areas. Activities as well as meals during dining are socially distanced. If facility were to experience staffing shortage, Agency staff would be brought into the facility.

No deficiencies noted during today's inspection
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021
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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