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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804053
Report Date: 01/19/2023
Date Signed: 01/19/2023 11:08:23 AM


Document Has Been Signed on 01/19/2023 11:08 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:NAZARETH ROSE GARDENS OF NAPAFACILITY NUMBER:
286804053
ADMINISTRATOR:GOCO, MARISOLFACILITY TYPE:
740
ADDRESS:903 SARATOGA DRIVETELEPHONE:
(510) 468-1909
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:44CENSUS: 26DATE:
01/19/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Wellness Director, Joey MendezTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 01/19/2023 to conduct a pre licensing inspection. LPA met with wellness coordinator, Joey Mendez. Administator, Marisol Goco arrived later. This is a change of ownership with residents in care. During the time of the inspection facility had 26 residents.

Upon arrival LPA self screened and signed in per facility protocol. LPA toured building and grounds which were found to be clean and in good repair. Exits and walkways were free from obstructions. Exit alarms were working properly. At time of LPA arrival breakfast had already been served. LPA observed posted menu. Facility had sufficient perishable and non-perishable food. LPA observed snacks being provided to residents during inspection. Carbon monoxide detectors were present throughout the facility. Fire extinguishers inspected were charged and current. Facility has smoke detectors and sprinklers. Fire panel was last inspected 06/2022. Medications were centrally stored and secured. Medications inspected were in their original containers. Facility uses a written medication administration record. Toxins were locked and secured. Facility had extra fresh linens and hygiene supplies available for residents. Bathrooms had necessary grab bars and non-slip mats. LPA and wellness director reviewed resident and staff record keeping. Facility keeps a closet with older staff/resident records and current records in admin office.

Comp III waived, administrator has been operating a licensed care facility.

No deficiencies observed during today's inspection. Exit interview conducted with administrator and a copy of this report emailed to the facility.

LPA will notify application unit to proceed with licensing.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/19/2023
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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