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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804025
Report Date: 05/07/2024
Date Signed: 05/07/2024 08:54:59 AM


Document Has Been Signed on 05/07/2024 08:54 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: 4DATE:
05/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Luisita Makalintal, staffTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Hansen arrived unannounced on this day 5/7/2024 to conduct a Case Management -Plan of Corrections (POC) visit. Staff/LPA attempted to call Licensee/Admin Madonna Martinez but could only leave message regarding today's visit.

On 3/28/2024 LPA conducted a continuation of annual inspection and cited facility 5 citations on deficiencies observed during inspection: 87705(c)(5) Care Persons with Dementia, resident did not have a physician’s report, 87463(c) Reappraisals, resident did not have reassessed care plan, 1569.618(c)(3) Employee Scheduling, staff did not have required current CPR or First Aid certification, 87411(f)Personnel Requirements, staff did not have health screening or TB report, & 87465(i) Incidental Medical and Dental Care, 4 months of medications to be destroyed were still at facility. Plan of Correction (POC) date for all was 4/10/2024. LPA gave extension to Licensee on 4/19/2024 to submit all POC’s by 4/22/2024. Facility did not clear citations and on 4/30/2024 LPA re-cited for all 5 citations & included citation 87405(a) Administrator – Qualifications and Duties as the RCFE Administrator's Certificate expired on June 20, 2023; A renewal application was submitted on February 26, 2024; The status of the renewal application is pending; The Administrator has stated that a renewal application was submitted timely in 2023 but has not produced documentation to prove the claim. LPA has conducted multiple visits and has yet to meet with the Administrator. All 6 POC’s were due 5/2/2024.

Licensee has not corrected the POC’s by the due date. Civil Penalties issued for all 6 citations.



Civil penalties are being assessed today in the amount of $500 X 6 = ($3,000.) for failure to correct POC’s and will continue to run at $100.00 per day per citation until corrected.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. 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: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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