286804025-4-24-2023-21-AS-VBEI-CR7S9T-20230424134113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804025
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:41:23 PM

Document Has Been Signed on 04/24/2023 01:41 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
SANTA ROSA RO, 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:	04/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Administrator, Madonna Grace Martinez		TIME COMPLETED:	01:55 PM

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 Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Madonna Grace Martinez arrived later. Upon arrival, LPA observed that there was a screening station located outside along with Covid-19 signage and a poster advising individuals to wear masks. Staff was not wearing a mask. LPA spoke with Administrator who stated that masks were no longer required but they continued to screen visitors to encourage them not to visit the facility if they are not feeling well. LPA directed Administrator to update their Infection Control Plan to reflect facility policy on masking and screening. LPA initiated a tour of the facility around 10:20am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Per staff, the water heater stopped working today and the Administrator is working on having a vendor come out to repair or replace the water heater. Staff provided the proof of service from the utility company indicating the need for repair. Facility has a plan to disinfect dishes and care for residents until water heater is repaired or replaced. Extra hygiene products and linens were available. Cabinet in kitchen containing cleaning supplies and cabinet containing knives was locked with a baby lock. LPA discussed the limitations of a baby lock in order to keep dangerous items inaccessible and discussed other options with Administrator. LPA observed a can of disinfectant in the bathroom cabinet that was not locked allowing access to residents in care. Staff immediately locked cleaner. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Fire extinguisher was last inspected February 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational. Most recent fire/disaster drill was conducted January, 2023. Continued on LIC809C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ZEALCARE HOME	FACILITY NUMBER: 286804025
	VISIT DATE: 04/24/2023

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
26
27
28
29
30
31
32

Continued from LIC809

Four staff files and five resident files were reviewed. Administrator Certificate for Administrator, Madonna Grace Martinez 6053462740 expires 6/20/2023. Medications and medication records were reviewed.

Licensee/Administrator to submit updates of the following documents by 5/24/2023:
Proof of Liability Insurance
LIC308 Designation of Facility Responsibility (if applicable)
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/24/2023 01:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ZEALCARE HOME	FACILITY NUMBER: 286804025
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having a disinfectant in an unlocked cabinet accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2023
	Plan of Correction
1 2 3 4	Staff immediately locked disinfectant. Deficiency is cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3