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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804025
Report Date: 07/20/2022
Date Signed: 07/20/2022 11:21:34 AM


Document Has Been Signed on 07/20/2022 11:21 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 HOMEFACILITY NUMBER:
286804025
ADMINISTRATOR:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:2504 REDWOOD RD.TELEPHONE:
(707) 258-9348
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 5DATE:
07/20/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff, Luisita MakalintalTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 07/20/2022 to conduct a Post Licensing Inspection. Upon arrival LPA filled out a COVID screening form. Staff took LPA's temperature. Licensee/administrator was not available during the inspection but was notified over the phone. Licensee/administrator agreed to have LPA perform inspection with staff, Luisita Makalintal.

LPA toured building and grounds with staff. Facility was clean and in good repair. All exits and doorways were unobstructed. During the pre-licensing inspection it was noted that three out of five resident bedrooms did not have lamps as required per regulation. LPA observed lamps in all resident bedrooms during inspection on 07/20/2022. Long term care ombudsman poster was displayed prominently in the front entrance. LPA measured water temperature in bathroom shower faucet at 120.3 degrees F which is above the maximum allowable amount of 120 degrees F. LPA provided technical assistance and requested licensee submit a 7 day temperature log documenting temperature for shower faucet after adjustments. Water temperature in the kitchen sink was measured at 123.6 degrees F, per staff this faucet is not accessible to residents. Medications were locked and inaccessible to residents in care.

LPA requested licensee/administrator submit updated copies of the following by 08/01/2022:

LIC 9020
Admission Agreement
Copies of staff First Aid/CPR Training
Medication Administration Record for 1 Week

No deficiencies observed during the inspection. Exit interview conducted with staff, and a copy of the report printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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