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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803725
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:00:56 PM


Document Has Been Signed on 12/12/2023 03:00 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: 5DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Angelina Simi, AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA met with Administrator, Angelina Simi for today’s visit. There is a total of 5 residents, 4 with a diagnostic of dementia. There is 2 residents currently on Hospice.

LPA toured the facility on 12/12/2023 at 10:50 AM with administrator Angelina Simi; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The facility serves residents with dementia and has a plan of operation for special care and programming. All bedrooms have lighting & appropriate furnishings. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked cabinet in the laundry area, although cleaning detergents (Clorox bleach, spray & wipes) were found underneath both unlocked resident bathroom sinks at 10:55 am (see LIC809-D) Administrator removed items immediately. Hot water temperature measured 102.3 degrees F and 126.5 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 2 of 2 resident’s bathrooms while touring facility on 12/12/2023, (see LI809-D). Administrator informed facility just had pluming work that might not have fully corrected problem and scheduled follow up with plumber today. 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. Fire Extinguisher was found to be last charged on 9/15/2023 at the time of the visit. Smoke detectors and carbon monoxide detectors were found to be operational during the visit.

A review of 5 residents & 3 staff records as well as two resident’s medications was conducted during this visit. LPA reviewed resident’s files at 12:15 PM on 12/12/2023 and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A) on file.



Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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 5


Document Has Been Signed on 12/12/2023 03:00 PM - It Cannot Be Edited

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: VIEWMONT VILLA
FACILITY NUMBER: 286803725

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation & interview with Licensee, the licensee did not comply with the section cited above in 3 out of 3 (2 Lysol w bleach containers under unlocked resident bathroom sinks) & (paint cans on side of pourch ) were accessible to clients, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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Administrator moved all items at time of visit but was unaware of staff who put items in place. Administrator to conduct trainings for all staff regarding regulation and submit document stating name of training, names of staff, signatures & dates by 12/19/2023 to clear citation.
Type B
Section Cited
CCR
87303(e)(2)
87303(e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation & interview Administrator, the licensee did not comply with the section cited above in 2 out of 2 residents bathroom water faucets measured 102.3 degrees F & 126.5 degrees F, which are not within the allowable ranges of 105 to 120 degrees F., which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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Administrator has contacted origional plumber to address water temperature regulation and delivery. Administrator will submit repair receipt from plumber. Licensee will also submit as proof of correction a week measurement log of water temperature readings, taken once in the morning and once at night, showing temperatures in compliance with regulation 87303(e)(2), 2nd poc date Jan. 1, 2024
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: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


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: VIEWMONT VILLA
FACILITY NUMBER: 286803725
VISIT DATE: 12/12/2023
NARRATIVE
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At approximately 1:15 PM LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff files have proof of annual training requirements on file. LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed.

Medications were centrally stored in locked cabinet in the facility kitchen area. The Medications of 2 out of 2 residents were found to be given according to physicians’ directions on 12/12/2023 at 2:00PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be completed and accurate.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time; only need to update email & add Admin.’s mobile. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills are conducted quarterly with the latest on 9/15/2023. Angelina Simi Administrator Certificate # 6056410740 expires on 6/14/2024.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.


Continue on LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: VIEWMONT VILLA
FACILITY NUMBER: 286803725
VISIT DATE: 12/12/2023
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LPA Hansen is requesting facility to submit the following documents to CCL by 1/15/2024:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrators Certificate
Copy of Control of Property/New updated Lease
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5