286804062-6-10-2022-21-AS-KWAS-CF9RPS-20220610131226

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804062
Report Date: 06/10/2022
Date Signed: 06/10/2022 01:14:09 PM

Document Has Been Signed on 06/10/2022 01:14 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:	4K SENIOR HOME, LLC		FACILITY NUMBER:	286804062
ADMINISTRATOR:	HERNANDEZ, MARIA SOCORRO		FACILITY TYPE:	740
ADDRESS:	4147 MAHER STREET		TELEPHONE:	(707) 226-1293
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 5	DATE:	06/10/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Maria Socorro Hernandez		TIME COMPLETED:	01:21 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) K. Walters arrived unannounced and met with staff. Applicant, Maria Socorro-Hernandez (MSH) arrived later. The Current Licensee, Leni Stayman was also present for today's visit. The purpose of this visit is to conduct a Pre-Licensing inspection. The applicant submitted an application to change ownership to the centralized application unit. The facility is currently licensed as Stayman Estates-Maher, facility number 286801894. Once the change of ownership is approved, the facility will be licensed as 4k Senior Home, LLC. LPAs conducted a risk assessment with staff and MSH, who will be the Administrator once the license is approved. The facility is a one story home with 4 bedrooms for residents, 2 staff rooms, living room, family room, 2 bathrooms and kitchen. The City of Napa's fire prevention division office granted the facility clearance for 6 non-ambulatory residents. The grounds of the facility were fenced and there was a shaded area available for residents use. There were no accessible bodies of water or firearms. The fire extinguisher was last inspected on 02/03/2022. There were 11 Smoke and 9 carbon monoxide detectors, which were tested and appeared to be operational. A emergency disaster plan was submitted, and the applicant has identified at least two evacuation locations. The applicant submitted an infection control plan, which has been approved. When LPA toured the facility LPA observed that components of the infection control plan were in place. All individual who entered the facility were wearing mask. There was a sign-in sheet for visitors and temperature gun. There was at least a 30 day supply of incontinence products and personal protective equipment available. Facility has developed a checklist to document each time the facility is disinfected. Continued on 809 C

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

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: 4K SENIOR HOME, LLC	FACILITY NUMBER: 286804062
	VISIT DATE: 06/10/2022

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Continued from 809

LPA observed locked cabinets for sharps and medications. Kitchen was spacious and clean, adequate supply of dishes and utensils. Refrigerators were clean, with perishable and non-perishable foods. Garage cabinets and several shelves were supplied with can/dry goods, paper products and emergency water. Bathrooms had slip mats and grab-bars for residents safety. Hand washing supplies and paper products were available. In sinks used by residents, water temperature read at 116 & 119 F. A tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing.

LPA observed the following postings: Ombudsman poster, hand washing, masks required, personal rights, emergency disaster drills, staff roster, activity poster and menu. Applicant had the Let Us Know Complaint poster, but it was the incorrect size. Applicant and current Licnesee ordered the poster during the visit.

LPA conducted a COMP 3 with applicant some of the following items were discussed: Administrator Qualifications, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Criminal Background clearance, Acceptance and Retention, Restricted and Prohibited Health Care Conditions

This pre-licensing is complete. LPA will submit the pre-licensing reports to Application Unit Analyst in Sacramento; Application Unit Analyst will notify applicant of application status. A copy of the report was given to the Applicant.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC809 (FAS) - (06/04)

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