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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803264
Report Date: 11/02/2021
Date Signed: 11/02/2021 11:28:49 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: 34DATE:
11/02/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Minerva Villegas (Wellness Coordinator)TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted a case management visit to cite deficiencies discovered during a complaint investigation and met with Wellness Coordinator, Minerva Villegas.

LPA learned through interviews on 9/22/21 with Administrator, the facility staff is not following their Dementia Care Program Plan dated 2/5/2020 which states: “Re-evaluation and updating of assessment plan will be completed an updated every quarter instead of every six month for more frequent scheduling of care conferences with family regarding resident’s current condition”. “Hourly monitoring form per shift will be reviewed by Administrator on a daily basis”.

Based on records review of (R1) Physician report dated 10/16/2020 with a diagnose of Severe Dementia and care plan LIC625 dated 2/8/21 was not reviewed and signed by R1’s responsible party. Also, hourly monitoring sheets provided by facility revealed that on 5/29/21 R1 was not assisted with incontinence care during the time frame of 6am to 7am of next day. Per R1’s service plan dated 2/8/21 which was not signed by resident or responsible party indicated that R1 will be provided with full assist: “security checks every two hours and as needed”; “R1 requires one bed check per night per safety reasons”. R1 has a diagnosis of Severe Dementia on their physician report that requires full assistance with some ADLs including standby assist while using the bathroom. Also, it was revealed during visits conducted to the facility and records review of facility program plan dated May 2010 that call light system is not included in the program plan and facility currently does not have a current policy about system.

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) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited

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Type A 87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, social functioning & appropriate assistance is provided when such observation reveals unmet needs…This requirement is not met as evidenced by:
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Based on LPA/Administrator observation, interviews & records review of hourly monitoring forms revealed that facility did not ensure that on 5/29/21 R1 was assisted with incontinence care during timeframe of 6am-7am of next day as stated on R1’s services plan. During visit on 9/9/21 LPA/W. Coordinator tested & pulled alarms & staff were not alerted which poses an immediate health and safety risk to residents in care.
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Type B
11/16/2021
Section Cited

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B 87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidenced by:
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Based on record review, the facility did not ensure to have current reappraisals signed by responsible parties on 5 out 5 residents did not have reappraisals within 12 months as stated on their facility plan posing 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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