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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804041
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:20:05 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2023 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20230104161110
FACILITY NAME:NAZARETH CLASSIC CARE OF NAPA INCFACILITY NUMBER:
286804041
ADMINISTRATOR:RAGLAND, SHANTIFACILITY TYPE:
740
ADDRESS:2465 REDWOOD ROADTELEPHONE:
(510) 468-1909
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:46CENSUS: 23DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Minerva VillegasTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility mismanaged resident's medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/16/2023 to conduct a complaint inspection regarding the allegation that facility mismanaged resident’s medications. LPA met with administrator, Minerva Villegas.

During the inspection LPA conducted interviews, reviewed records and made observations. Medications were locked and secured in a central medication room. Individual resident medications are kept separated in labeled bins. Overflow medication is also kept locked, labeled and separated by resident. LPA was able to review current month’s medication administration record. Previous month’s records are moved to resident files which were also reviewed. Facility logs and dates medications upon receiving them. LPA was shown records for medication destruction.


Continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20230104161110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: NAZARETH CLASSIC CARE OF NAPA INC
FACILITY NUMBER: 286804041
VISIT DATE: 02/16/2023
NARRATIVE
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It is alleged that facility gave Resident 1 (R1) a medication after the physician had ordered it be stopped. Orders were found in R1’s file to stop medication dated 11/03/2022. Last dose was given 11/02/2022. Medication destruction record indicated the remaining medication was destroyed on 12/01/2022. Although the allegation may be valid there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegation is unsubstantiated.

No deficiencies cited during today’s inspection.

Exit interview conducted with administrator and a copy of this report sent to her email.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2