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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803725
Report Date: 11/04/2022
Date Signed: 11/04/2022 01:53:36 PM


Document Has Been Signed on 11/04/2022 01:53 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:VIEWMONT VILLAFACILITY NUMBER:
286803725
ADMINISTRATOR:SIMI, ANGELINAFACILITY TYPE:
740
ADDRESS:3158 BROWNS VALLEY ROADTELEPHONE:
(707) 255-8811
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 6DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Angelina SimiTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 11/04/2022 to conduct a required - 1 year inspection. LPA was greeted and screened by staff. Administrator, Angelina Simi arrived shortly. This inspection is focused on the infection control practices and procedures of this facility.

LPA toured building and grounds which were found to be clean and in good repair. Facility currently has six residents. Resident bedrooms are located on the first floor. The amount of fresh and non-perishable food was within regulation. Fire extinguishers inspected were charged and current. Toxins were locked and secured. Medications were centrally stored and locked. Carbon monoxide and smoke detectors were present and operational. Walkways were cleared and unobstructed. High touch surface areas are disinfected daily. LPA observed COVID postings at the front entrance. Staff and residents are all fully vaccinated. Administrator has necessary Personal Protective Equipment to support a resident in isolation. LPA and administrator discussed resident/staff record keeping. Staff have been given infection control training.

LPA requested the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 Designation of Administrative Responsibility
Liability Insurance
LIC 610 Emergency Disaster Plan
Register of Clients
LIC 500 Personnel Report

No deficiencies observed during today's inspection. Exit interview conducted with administrator and a copy of this report emailed to the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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