286804053-4-18-2023-21-AS-MCUA-CQZQNY-20230418121954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804053
Report Date: 04/18/2023
Date Signed: 04/18/2023 12:20:05 PM

Document Has Been Signed on 04/18/2023 12:20 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 ROSE GARDEN OF NAPA		FACILITY NUMBER:	286804053
ADMINISTRATOR:	GOCO, MARISOL		FACILITY TYPE:	740
ADDRESS:	903 SARATOGA DRIVE		TELEPHONE:	(510) 468-1909
CITY:	NAPA	STATE: CA	ZIP CODE:	94559
CAPACITY:	44	CENSUS: 23	DATE:	04/18/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:43 AM
MET WITH:	Marisol Goco (Administrator)		TIME COMPLETED:	12:34 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a post-licensing inspection. LPA met with Administator, Marisol Goco. The facility has residents receiving hospice services and there are residents with a diagnose of Dementia. Upon arrival LPA was screened and signed in per facility protocol. Facility is a one story building and is approved by Napa Fire Department for 44 non-ambulatory resident's room capacity of which 10 may be bedridden. LPA/staff 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. LPA observed required postings. Facility had sufficient perishable and non-perishable food. LPA observed residents were participating in an exercise activity. Facility has first aid kit which was found to be appropriate during the Post-Licensing inspection. There is outdoor space for activities. LPA obtained a copy of activity calendar and weekly dated menu was also observed. All resident’s bedrooms have lighting & appropriate furnishings, and resident’s beds were outfitted with mattress pads as required by Title 22 Regulations. Carbon monoxide detectors were present throughout the facility. Fire extinguishers inspected were charged and current as of July 2022. Facility has smoke detectors and sprinklers. Fire panel was last inspected 07/2022. Last disaster drill was conducted on January 2023. Hot water temperature measured at 104.5, 106.2, 114.4 and 116.9 degrees in resident's bathrooms which is within regulation. Bathrooms had necessary grab bars and non-slip mats.Medications were centrally stored and secured. Medications inspected were in their original containers. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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 ROSE GARDEN OF NAPA	FACILITY NUMBER: 286804053
	VISIT DATE: 04/18/2023

NARRATIVE

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Continued from LIC809...

Facility uses a written medication administration record and provided a copy of their last medication audit conducted by an outside agency dated 10/22 stating the facility was found in compliance with medication storage, first aid kit, medication centrally stored, destruction records including medication refrigerator storage and controlled narcotics. Toxins were locked and secured. Facility had extra fresh linens and hygiene supplies available for residents.

During today's post-licensing inspection, LPA reviewed six residents and six staff files. Residents have current medical assessments, but their needs and services care plans needs to be reviewed and signed by their responsible parties for 5 out of 6 residents. Staff records indicated that CPR/1st aid and staff have received required annual training hours. Admission agreements were updated with an addendum indicating the change of ownership. Surveillance cameras use in common areas were included in previous admission agreements. Administrator certificate for Marisol Goco # 6018647740 expires on 8/2/2024.

Administrator will provide copies of the following by 4/25/2023: 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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/18/2023 12:20 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAZARETH ROSE GARDEN OF NAPA	FACILITY NUMBER: 286804053
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87467(a)(3)

Resident Participation in Decisionmaking

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in 5 out of 6 residents records reviewed care plans were not reviewed and signed within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/02/2023
	Plan of Correction
1 2 3 4	Administrator will review resident's care plans to ensure that resident or their responsible parties have reviewed and signed current needs and services plans. Administrator will submit a self-certification LIC9098 notifying CCL that they have met with resident's responsible parties and their care plans are up to date by POC due date.

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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