286804025-4-7-2022-21-AS-VWIS-CD9P2V-20220407105635

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804025
Report Date: 04/07/2022
Date Signed: 04/07/2022 10:56:41 AM

Document Has Been Signed on 04/07/2022 10:56 AM - 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:	ZEALCARE HOME		FACILITY NUMBER:	286804025
ADMINISTRATOR:	MARTINEZ, MADONNA GRACE		FACILITY TYPE:	740
ADDRESS:	2504 REDWOOD RD.		TELEPHONE:	(707) 258-9348
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 6	DATE:	04/07/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Applicant, Madonna Grace Martinez		TIME COMPLETED:	11:06 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Victoria Willis arrived announced to conduct a Pre-Licensing Inspection and was greeted by a caregiver. Applicant, Madonna Grace Martinez arrived later. Upon arrival, the on duty caregiver took LPA's temperature and LPA filled out a questionnaire with standard Covid-19 screening questions. Applicant has applied for a Change of Ownership at this location and there are already six residents in care. LPA initiated a tour of the facility at approximately 9:20am and made the following observations: Facility is a one story residence with four single resident bedrooms, one shared resident bedroom two bathrooms and common areas. All resident rooms are furnished with a bed, dresser, chair and bedside table, however, three of five resident bedrooms did not have a lamp. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathroom read at 133 degrees F which is not within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. Facility backyard has multiple areas for visiting and activities. Facility received an approved fire clearance dated December 3, 2021 that allows for six non-ambulatory residents. Fire Extinguisher was last serviced February 2022. Carbon Monoxide detectors were tested and operational. Facility has lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage. Facility has a emergency supply of bottled water. LPA observed the CCL Complaint Poster in the main doorway. The Long Term Care Ombudsman Poster was in the kitchen but is blocked when the door is open. LPA requested that the Ombudsman Poster is moved to somewhere more conspicuous. Additionally, facility does not have Personal Rights or Rights to Resident Councils notifications posted. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

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: ZEALCARE HOME	FACILITY NUMBER: 286804025
	VISIT DATE: 04/07/2022

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Continued from LIC809

Medications and files are secured in the staff office and toxins/cleaning supplies are secured in a kitchen cabinet. LPA and Applicant discussed that all resident files would need to be updated upon Licensure. LPA confirmed that Applicant is signed up for the Guardian Provider Information Notices (PINs) that the department sends out.

Component III was waived due to Applicant being a current Licensee.

Applicant agrees to turn down water heater and send LPA a picture of water temperature reading within regulation, pictures showing that all residents have lamps for reading and all required postings on posted in a conspicuous place in order to move forward with Licensure. Once received, LPA will notify Application Unit so application process may proceed.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2022

LIC809 (FAS) - (06/04)

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