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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803264
Report Date: 03/22/2022
Date Signed: 03/22/2022 01:19:08 PM


Document Has Been Signed on 03/22/2022 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: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: 32DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Marisol GocoTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Nazareth Rose Garden of Napa for the purpose of conducting an Required 1 year inspection. LPA was met at the door by Administrator, Marisol Goco.

LPA toured the building and grounds with Administrator, Marisol Goco. Facility was found to be clean, in good repair and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. The amount of fresh and nonperishable foods was within regulation. Food stored in the kitchen refrigerators was properly stored as per regulations at the time of this inspection. Emergency food are stored in the kitchen. Toxins are stored inaccessible. Hygiene products are stored in the common shower room. Water temperature measured at 115 degrees within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers were last inspected on 10/2021. Smoke detectors are hardwired into the fire suppression system with a last inspection date bearing 10/28/2021. Carbon Monoxide detector were present and found to be operational during the inspection. First Aid kit was appropriately filled. Medication is centrally stored and secured. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307.

LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Facility has PPE supply stored in the office. Staff have had all PPE training required. Facility was N95 Fit tested on January 2022. Disaster drills were conducted in October 2021. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022
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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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: NAZARETH ROSE GARDEN OF NAPA
FACILITY NUMBER: 286803264
VISIT DATE: 03/22/2022
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LPA requested the following documents be sent to CCL:

-Updated LIC 200 indicating modifications/installation of new floor in the beauty salon and Carbon Monoxide detectors in every room.
-Facility sketch
-LIC 308 Designated Facility Responsibility
-LIC 500 Personnel Summary
-LIC 610 Emergency Disaster Plan
-LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
-LIC 9020 Register of Facility Client’s/Resident’s
-Copy of Administrator Certificate
-Copy of Certificate of Liability Insurance

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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