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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804041
Report Date: 07/18/2023
Date Signed: 07/18/2023 04:12:49 PM

Document Has Been Signed on 07/18/2023 04:12 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:NAZARETH CLASSIC CARE OF NAPA INCFACILITY NUMBER:
286804041
ADMINISTRATOR:MINERVA VILLEGASFACILITY TYPE:
740
ADDRESS:2465 REDWOOD ROADTELEPHONE:
(510) 468-1909
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 46CENSUS: 24DATE:
07/18/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Minerva Villegas-AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso conducted a continued Annual visit, on 7/18/2023 at approximately 10:15am, and met with Health & Wellness Director(HWD) Rafael Daatio. The HWD contacted the Administrator Minerva Villegas. The Administrator would arrive within an hour after being contacted.

Hospice care waiver approved for ten(10) residents. Facility has an approved dementia plan of operation. Facility has a required Infection Control Plan, which is part of the facility's plan of operation. Fire clearance approval is for 46 nonambulatory residents, of which 10 may be bedridden. All ten(10) smoke alarms were serviced and tagged as required- expires 5/4/24.

LPA toured the facility with the HWD. Hot water was checked at 109.8F., which is within regulation. Facility was observed to be at a comfortable temperature with portable air conditioners and fans throughout the facility during the inspection. LPA observed exits free from obstruction. LPA observed residents in the large dining area watching tv, and others at a large table participating in an activity with the Activities Director. Medications were locked up, and inaccessible to residents in care. All medications were stored appropriately within State and Federal Laws during the inspection. All toxins/cleaners are stored and locked up making them inaccessible to residents' in care. The facility had a sufficient supply of food. Facility had a sufficient supply of paper products, soap, hygiene supplies, and personal protective equipment(PPE) supply.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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: NAZARETH CLASSIC CARE OF NAPA INC
FACILITY NUMBER: 286804041
VISIT DATE: 07/18/2023
NARRATIVE
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The LPA reviewed five(5) resident files. All files were complete. The LPA reviewed five(5) staff files, including training. All staff have required criminal record clearance. All direct care staff have current First Aid, and CPR as required.

The LPA observed during the tour of the facility that there were approximately five(5)resident bedrooms, and shared bathrooms, that smelled strongly of urine. The residents that occupy the rooms are incontinent. There was also a toilet with feces left in it which left the whole room smelling of feces; The resident of this room is incontinent, uses a wheelchair, and needs to be assisted with toileting, cleaning and changing as needed. There was another room that was vacant but had a dirty diaper in a cabinet. This deficiency will be cited, 87625(b)(3) Managed Incontinence -The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition.the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence, see LIC809D.

The LPA observed that there were approximately five(5)resident bedrooms, and shared bathrooms, that smelled strongly of urine. Toilets were found to have old caulking around the bottom of the toilet(s) that was peeling off, stained yellow and brown, and in some areas the caulking was missing. This deficiency will be cited,87303(a)(1) Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition, see LIC809D.

The LPA observed that resident bathrooms had no paper towels available, and there were no paper towels in the paper towel machine in each restroom. LPA was told by staff (S2) that they don't put any paper towels in the restrooms and just hang a towel up on the bathroom towel bar for residents use.

Continued on LIC809C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
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: NAZARETH CLASSIC CARE OF NAPA INC
FACILITY NUMBER: 286804041
VISIT DATE: 07/18/2023
NARRATIVE
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Based on LPA's observation of no paper towels in restrooms checked. The bathrooms are not private but are to be used by residents in rooms that are on each side of the shared bathroom, jack and jill type. HWD stated to the LPA that facility doesn’t put any paper towels in the restrooms and just will hang a towel up in the bathroom for residents use. LPA didn't observe any towels in the bathrooms. Due to physical arrangements of the facility and/or the habits or condition of others in the facility, towels may be used by more than one resident, common towels are prohibited. A resident's bed was checked and when sheets were pulled back the bottom of the sheet had dirt and garbage all in it. This deficiency will be cited, 87307(a)(3)(C)Personal Accommodations and Services -The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited, see LIC809D.

Administrator will provide copies of the following by 8/18/2023: LIC 308 Designated of facility responsibility, LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan (if there are any changes), LIC 9020 Register of Facility Client’s/Resident’s, Copy of Administrator Certificate, Copy of Certificate of Liability Insurance

Deficiencies 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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/18/2023 04:12 PM - It Cannot Be Edited


Created By: Dina Alviso On 07/18/2023 at 02:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAZARETH CLASSIC CARE OF NAPA INC
FACILITY NUMBER: 286804041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87625(b)(3)
Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's [(observation) during the tour of the facility with HWD that there were approximately five(5) resident bedrooms, and shared bathrooms, that smelled strongly of urine. The residents that occupy the rooms are incontinent. There was also a toilet with feces left in it which left the resident's room smelling of feces; The resident of this room is incontinent, uses a
wheelchair, and needs to be assisted with toileting, cleaning and changing as needed. There was another room that was vacant but had a dirty diaper in a cabinet, the licensee did not comply with the section cited above in five(5) resident rooms and bathrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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Licensee/Administrator to clean the resident rooms, and bathrooms discussed during the inspection. Ensure residents are kept clean and dry, and that the facility also addresses the urine odor in the facility and these resident rooms/bathrooms. Submit plan of correction, cleaning the rooms and bathrooms, and maintenance plan on keeping the facility /resident rooms/bathrooms free of urine odor. Hold an inservice with staff regarding facility policies and procedures on managed incontinence, submit proof of training with plan of correction. POC due 7/28/23.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's [(observation)that there were five(5)resident bedrooms, and shared bathrooms, that smelled strongly of urine. Toilets were found to have old caulking around the bottom of the toilet(s) that was peeling off, stained yellow and brown, and in some areas the caulking was missing, the licensee did not comply with the section cited above in five(5) resident bathrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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Licensee/Administrator to have the five(5) bathroom toilets cleaned, and recaulked appropriately around the bottom of the toilet. Submit pictures of the bathrooms and toilets after you complete cleaning and caulking them with the POC; Submit a plan on maintaining facility bathrooms in a clean, safe sanitary manner, and in good repair at all times. POC due 7/28/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/18/2023 04:12 PM - It Cannot Be Edited


Created By: Dina Alviso On 07/18/2023 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAZARETH CLASSIC CARE OF NAPA INC
FACILITY NUMBER: 286804041

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services -Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation of no paper towels in restrooms checked. The bathrooms are not private but are to be used by residents in rooms that are on each side of the shared bathroom, jack and jill type. HWD stated to the LPA that facility doesn’t put any paper towels in the restrooms and just will hang a towel up in the bathroom for residents use. LPA didn't observe any towels in the bathrooms. Due to physical arrangements of the facility and/or the habits or condition of others in the facility, towels may be used by more than one resident, common towels are prohibited. A resident's bed was checked and when sheets were pulled back the bottom of the sheet had dirt and garbage all in it. and interview with HWD, the licensee did not comply with the section cited above in facility resident bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2023
Plan of Correction
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Licensee/Administrator to ensure all facility shared resident batthrooms have papertowels available for resident use as needed as common hand towels/any common towels are prohibited. Licensee to ensure all residents bed linens, are clean and are changed as required Submit plan of correction and ensure compliance with the regulation in regards to resident bed linens and paper towels in resident bathrooms for use as needed. .POC due 7/28/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023


LIC809 (FAS) - (06/04)
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