286804248-9-23-2024-21-AS-CARD-D9DRYV-20240923132659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286804248
Report Date: 09/23/2024
Date Signed: 09/23/2024 01:27:06 PM

Document Has Been Signed on 09/23/2024 01:27 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:	VINE HILL SENIOR LIVING		FACILITY NUMBER:	286804248
ADMINISTRATOR:	UY, NANCY		FACILITY TYPE:	740
ADDRESS:	2529 VINE HILL COURT		TELEPHONE:	(415) 846-4133
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 4	DATE:	09/23/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Applicant Safir Rezzoug		TIME COMPLETED:	01:40 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	At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, for the purpose of conducting a pre-licensing inspection and met with current Administrator Christina Ramirez. This pre-licensing inspection is being conducted due to a change of ownership. Applicant was not present at the time of this inspection. LPA contacted applicant and left a message that LPA was at the facility. Fire Clearance has been approved for a capacity of 6 residents; 4 of which may be non-ambulatory and 2 may be bedridden. There are currently 4 residents in care. LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and at a comfortable temperature with all doors and exits free from obstruction. Fire extinguishers found throughout the facility were charged and inspected within the last 12 months. Smoke detectors and carbon monoxide detectors in resident bedrooms and throughout the facility were tested and found to be operational. Exits of the facility and front entrance have appropriate auditory alarm systems and found to be functioning. Water temperature at faucets accessible to residents was measured and found to be above regulation, between 105 & 120 degrees F. There was an ample supply of fresh linens, continence care and hygiene products available. A tour of the kitchen and food supply was inspected and found to be clean and orderly. Food items were stored properly. Residents are provided various nutritious meals with alternate options and snacks readily available upon request. There was a sufficient amount of food for the number of residents in care. Continued on LIC 809-C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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: VINE HILL SENIOR LIVING	FACILITY NUMBER: 286804248
	VISIT DATE: 09/23/2024

NARRATIVE

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Cleaning supplies, laundry products and other toxins were properly secured in designated storage closets. Medications are centrally stored and secure. A spot medication review was conducted and Centrally Stored Medication Records were found to be in order.
At approximately 10:45AM, LPA reviewed 4 of 4 resident files. LPA observed there were 2 residents receiving hospice services. Hospice care plans were not present in the file. 2 of 4 files did not contain resident appraisals. 1 of 4 files did not contain a pre- admission appraisal. Application received by LPA does not contain information regarding whether a hospice waiver was requested or granted.
At approximately 11:15AM, Applicant Safir Rezzoug arrived at the facility. Applicant told LPA they did submit a Hospice Waiver request.

The Emergency Disaster Plan was reviewed and shows appropriate evacuation sites. Applicant will send verification of liability insurance to CCL once Licensed.

Component III orientation was conducted with the Applicant. The pre-licensing evaluation has been completed. LPA requested the following item be submitted before the application will be submitted for file review:
- 7 day hot water temperature log showing TWICE DAILY temperature readings for kitchen and resident common bathroom faucets.

Upon receipt of the above requested information, LPA will submit application for a final review and approval from the Licensing Program Manager.

This report was reviewed with applicant and a copy was provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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