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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804025
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:49:51 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/28/2024 02:49 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: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: 4DATE:
03/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Alice Jusi, StaffTIME COMPLETED:
03:00 PM
NARRATIVE
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License Program Analyst (LPA) Shannan Hansen arrived at 10:30 AM to complete an unannounced annual inspection and met with Alice Jusi, staff called Madonna Martinez, Administrator to inform of visit. LPA spoke with Admin who authorized staff to sign today. There is a total of 4 residents.

At approximately 10:40 am LPA recheck hot water temperatures in bathroom faucets used by residents, finding readings of 110.4 degrees F within regulations of 105 to 120 degrees F.

At approximately 11:15 AM, LPA reviewed 4 of 4 resident records and found 4 of 4 residents have current Pre-Admissions Appraisals on file and 1 resident is needing Re-Appraisals, Licensee did not have on file. (see LIC 809-D) Physician’s reports (602’s) were current for all residents except 1 who has a dementia diagnosis and did not have in file (see LIC809D).

At approximately 12:15 PM, LPA reviewed 5 of 5 staff records and learned, 5 of 5 staff (all work alone for some hours of shift) do not have proof of CPR training & 4 of 5 staff do not have proof of First Aid (see LIC809-D). Staff S1 does not have proof of Health Screening or TB clearance (see LIC 809-D).

At approximately 1:30PM, LPA conducted review of Medication records which were found to be thorough and contained physician’s orders for each resident. LPA observed approximately 8 bags of medications in locked medication cabinet needing to be destroyed for over 4 months. (see pic & LIC 809-D).

Administrator Certificate for Madonna Grace Martinez 6053462740 expired 6/20/2023. Administrator provided LPA proof they have sent in documents to renew certificate.



Continue on LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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: 03/28/2024
NARRATIVE
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LPA Hansen is requesting Licensee to update and submit the following documents by 4/24/2024 to SRRO:

LIC 308 Designation of Facility Responsibility (if changed)

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

Copy of Administrator Certificate

Proof of Liability Insurance

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..
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/28/2024 02:49 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: ZEALCARE HOME
FACILITY NUMBER: 286804025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
CCR
87705(c)(5)

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 87705(c)(5) Care Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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Administrator agrees to send in proof of current medical assessment for resident R1 and statement they understand regulation 87705(c)(5) by POC due date of 4/10/2024.
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This requirement was not met as evidenced by: during inspection of R1's records it was observed R1 did not have a Physician Repoprt & Admin informed it was taken out to be replaced with updated after visit that has been scheduled . This is a potential risk to the health and safety of residents in care
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Type B
04/10/2024
Section Cited
CCR87463(c)

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87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by:
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Administrator agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date 4/10/2024.
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Based on LPA file review showing that resident's care plans for 1 out of 4 resident (R1) were not been performed within last 12 months. This is a potential risk to the health and safety of residents in care.
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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: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/28/2024 02:49 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: ZEALCARE HOME
FACILITY NUMBER: 286804025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
HSC
1569.618(c)(3)

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1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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Administrator to ensure that at least one staff on duty has CPR training at all times & all staff have First Aid. Administrator to submit proof of staff S1-S5 have current --
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This requirement was not met as evidenced by: Based on interview the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 5 out of 5 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.
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CPR trained per regulation and S1-S4 have proof of current First Aid given by American Red Cross by POC due date 4/10/2024 or contact LPA to request extension.
Type B
04/10/2024
Section Cited
CCR87411(f)

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87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.
This requirement is not met as evidenced by:
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Administrator to submit a health screening, including a TB test, and results and to submit copies of the documents to CCL by POC due 4/10/24.
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Based on review of records, Staff S1 lack a health screening report, including TB test and results. the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5


Document Has Been Signed on 03/28/2024 02:49 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: ZEALCARE HOME
FACILITY NUMBER: 286804025

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2024
Section Cited
CCR
87465(i)

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87465(i) Incidental Medical and Dental Care (i) Prescription medications which are not taken.. upon termination of services..are otherwise to be disposed of shall be destroyed.

This requirement is not met as evidenced by:
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Administrator to ensure that facility is following required destruction procedures at all times. Items must be immediately destroyed according to Title 22 procedures.
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Based on LPAs observation and discussion with Administrator that the facility did not destroy aprox 8 bags of medications that have been kept for aprox 4 months, poses/posed a potential health, safety or personal rights risk to persons in care.
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Administrator to sign self-certification that they have reviewed regulation 87456 Incidental Medical and Dental Care. Administrator agrees to send LPA Hansen self certification by 4/10/2024.

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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: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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