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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804053
Report Date: 12/27/2023
Date Signed: 12/27/2023 03:27:02 PM


Document Has Been Signed on 12/27/2023 03:27 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 NAPAFACILITY NUMBER:
286804053
ADMINISTRATOR:VILLEGAS, MINERVAFACILITY TYPE:
740
ADDRESS:903 SARATOGA DRIVETELEPHONE:
(510) 468-1909
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:44CENSUS: 19DATE:
12/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Minerva Villegas, AdministratorTIME COMPLETED:
03:40 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA was welcomed by staff Josefina Harris who contacted Administrator, Minerva Villegas for today’s visit. Current Administrator Villegas and soon to be Administrator Shanti Subba Pickett arrived during the inspection. There is a total of 19 residents, 14 with a diagnostic of dementia. There is 8 residents currently on Hospice.

LPA toured the facility on 12/27/2023 at 8:50 AM with staff; facility was found to be clean and in good repair at a comfortable temperature with all exits free from obstruction. Exit alarms were working properly. Facility serves residents with dementia and has a plan of operation for special care and programming. All bedrooms inspected have lighting & appropriate furnishings. LPA observed residents were participating in an exercise activity. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins were locked and secured. Facility has extra fresh linens and hygiene supplies available for residents. Hot water temperature measured 110.1, 118.7, 122.3, 123, 129.7, 137.8 & 140.5 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 5 resident’s bathrooms & the 2 shower rooms while touring facility on 12/27/2023, (see LIC809-D). Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Facility has smoke detectors and sprinkler system. Fire panel was last inspected 10/26/2023. Fire Extinguisher was found to be last charged on 7/26/2023 at the time of the visit. Carbon monoxide detectors were found to be operational during the visit.

A review of 5 residents & 5 staff records as well as resident’s medications was conducted during this visit. LPA reviewed resident’s files at 11:15 AM on 12/27/2023 and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A) on file.


Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
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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Document Has Been Signed on 12/27/2023 03:27 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: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with Administrator & record review, the licensee did not comply with the section cited above by only conducting disaster drills 1 to 2 times per year as log notes last drill 3/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Licensee agrees to conduct and document disaster drills every 3 months on all shifts with all direct care staff. Licensee agrees to conduct a disaster drill on all shifts with all direct care staff and submit proof to CCL by POC 1/5/2024
Type B
Section Cited
CCR
87411(c)(1)

87411(c )(1) Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's Interview with Administrator and record review, two out of four staff lacked required first aid certification, the licensee did not comply with the section cited above in two out of four staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/05/2024
Plan of Correction
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Administrator to ensure all staff have required first aid certification training. Submit proof of staff's first aid certification by POC due date of 1/5/2024.
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) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


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: 12/27/2023
NARRATIVE
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At approximately 1:15 PM LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff files have proof of annual training requirements on file. LPA was presented with proof of CPR; although 2 of 4 care staff (S1 & S2) files reviewed did not have current 1st Aid certification (see LI809-D).

Medications inspected were in their original containers. Facility has a written medication administration record (MAR) and provided a copy of their last medication audit conducted by an outside agency dated 10/20/2023 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.

LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time, although there is a new Administrator change. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have only been conducted once to twice a year, with the latest 3/2023 (see LIC 809-D). Minerva Villegas Administrator Certificate # 6065970740 expires on 10/21/2025.
Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) 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 and appeal of rights provided.


LPA Hansen is requesting facility to submit the following documents to CCL by 1/15/2024:
LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Current Administrators Certificate
Copy of Control of Property/New updated Lease
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/27/2023 03:27 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: 12/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)

87303 Maintenance and Operation (e)Water supplies...shall be maintained... (2) Faucets used by residents...Hot water temperature controls shall be maintained...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made, Licensee did not comply with the section cited above. Sinks were observed with the following temperatures 122.3, 123, 129.7, 137.8 & 140.5 degrees F. This poses an immediate health, safety, and personal risk to residents in care.
POC Due Date: 12/28/2023
Plan of Correction
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Licensee to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F. Licensee to submit a self-certification stating they will do the following log: by POC due date of 12/28/2023 Facility to adjust temperature and submit a 10 day log checking water twice a day by POC due date of 1/8/2024 in order to clear this citation.
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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2023
LIC809 (FAS) - (06/04)
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