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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804025
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:14:17 PM


Document Has Been Signed on 06/12/2024 12:14 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 HOMEFACILITY NUMBER:
286804025
ADMINISTRATOR:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:2504 REDWOOD RD.TELEPHONE:
(707) 258-9348
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: DATE:
06/12/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Madonna MartinezTIME COMPLETED:
12:30 PM
NARRATIVE
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An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Regional Manager, Carla Nuti-Martinez, Licensing Program Managers, Bethany Moellers and Kimberley Mota, Licensing Program Analysts, Julie Florio, David Leibert, and Jill Nakagawa, Administrators, Madonna Martinez and Gwen Martinez.

The purpose of the informal meeting was to discuss citations for deficiencies observed on March 28, 2024, and recited on April 30, 2024, for failure to correct Plan of Corrections (POC) by the due date, as well an additional citation issued on this date.

The following areas of concern were discussed:

- Reporting Requirements
- Administrator to ensure clearing POCs and responding to Community Care Licensing (CCL) communication requests.

Administrator to submit the following outstanding POCs to CCL by COB 6/14/2024. Licensee was informed failure to submit by agreed upon date may result in additional civil penalties.

- Administrator to sign self-certification stating they have reviewed regulation 87456 Incidental Medical and Dental Care.
- 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 CPR training per regulation and S1-S4 have proof of current First Aid given by American Red Cross.
- Administrator to submit copies of health screening by a physician, including a TB test and results for staff member S1. ** Licensee informed S1 is no longer working in facility and will submit written notice that all staff will have required documents on file for CCL review.

Continued on 809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
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: 06/12/2024
NARRATIVE
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Continued from LIC809...

- Administrator to send in proof of current medical assessment for resident R1 and statement from Administrator acknowledging their understanding of regulation 87705(c)(5)
- Administrator to review all residents’ care plans, update them accordingly, and send self-certification to CCL that this process is complete.

Licensee was informed that a citation is being issued today for administrator qualifications and duties, a written plan is requested to clear the citation due by 6/14/2024.

The following deficiencies were observed (see LIC 809-D) 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 with Administrator and appeal of rights provided. Signature on form confirms receipt.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/12/2024 12:14 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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2024
Section Cited
CCR
87405(d)(a)(1)

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87405(d)(a) - (d)The administrator shall have the qualifications specified... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.

This requirement is not met as evidenced by:
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Licensee to ensure that the facility has a qualified, certified RCFE Administrator on-site as required by regulation. Licensee will also have a designated person listed on LIC308 to ensure continuity of care and operating regulations are met in the absence of Administrator.
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inspection, the licensee diLPAs interviews, observations and records reviewed which show that Adminstrator has not been present a sufficent number of hours to properly meet the responsibilities of operating the facility. This is a potential risk to the health and safety of all residents in care.
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Submit the following documents to CCL by COB 6/14/2024: LIC500, LIC308, copy of Administrator's Certificate. Attn: LPA Florio

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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) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024
LIC809 (FAS) - (06/04)
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