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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804316
Report Date: 07/27/2026
Date Signed: 07/29/2026 04:33:11 PM

Document Has Been Signed on 07/29/2026 04:33 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:HOME SWEET HOME OF NAPAFACILITY NUMBER:
286804316
ADMINISTRATOR/
DIRECTOR:		DASTGHEIB, ALI SINAFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 5DATE:
07/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Raymond A. Go, Designated Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
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At approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Raymond A. Go, Designated Responsible Party (DRP). Licensee/Administrator was contacted via telephone and was unable to attend today's inspection. Facility is an Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. The community has a Hospice waiver for six (6) and is approved for one (1) bedridden resident.

At approximately 11:00 AM, LPA initiated a tour of the community with DRP and observed the following: Facility is a one story building and was a comfortable temperature. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. Closets containing cleaning supplies and other items that could pose a risk were locked. The community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are covered seating areas and outdoor space for activities. Facility has internet service and a designated internet access device available to for resident use.

The community's fire extinguishers were observed charged and were last serviced 07/2026. smoke and Carbon Monoxide detectors were tested operational during today's inspection. Facility conducts quarterly emergency/disaster drills with the last one conducted 05/2026. LPA observed facility's infection control plan and emergency disaster plan which was last updated 11/2023. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community.

continued on LIC809C...
Bethany Moellers
Julie Florio
DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: HOME SWEET HOME OF NAPA
FACILITY NUMBER: 286804316
VISIT DATE: 07/27/2026
NARRATIVE
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Continued from LIC809...
Based on the facility sketch and fire clearance dated January 13, 2025, resident room #1 is cleared for two residents and has two exits. There are no additional structures or modifications pictured on the sketch or mentioned in the clearance. During facility walk through, LPA observed resident room #1 with a half wall and an accordion door installed and latched closed at the top near the ceiling on one side and a night stand and bedside commode placed in front of the door obstructing it, and preventing the rear resident from exiting through the main doorway, (see LIC809D and LIC421IM).

At approximately 12:30 PM, LPA reviewed five (5) resident records and five (5) staff records. Two (2) out of five (5) resident's records were observed missing a current physician's report and proof of negative TB results, (see LIC809Ds). Five (5) out of five (5) resident records reviewed were observed to contain the remaining required documents. Five (5) out of five (5) staff records have the required paperwork and proof of current First Aid/CPR certification. However, three (3) out of five (5) staff files reviewed were observed missing proof of all of the required initial training hours and proof of all of the required initial medication training hours, (see LIC809Ds).

Medication and medication records were reviewed and were observed managed and stored in compliance with regulation.

Facility works with residents and their families to coordinate medical and dental visits as well as transportation to and from appointments. Facility does not manage P&I cash resources.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
-LIC610E - Emergency Disaster Plan (updated)

Deficiencies are being cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Failure to correct the deficiencies by the plan of correction date and/or repeat deficiencies within a 12 month period may result in civil penalties.

**An Immediate Civil Penalty in the total amount of $500 is being assessed for the observed latched accordion door in resident room #1 which was latched near the top and obstructed by a night stand and bedside commode, which is a fire clearance violation and immediate health, safety, and/or personal rights violation to persons in care. (See LIC421IM).**



Exit interview conducted with DRP whose signature on form confirms receipt.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2026
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/29/2026 04:33 PM - It Cannot Be Edited


Created By: Julie Florio On 07/27/2026 at 05:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HOME SWEET HOME OF NAPA
FACILITY NUMBER: 286804316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 1 accordion doors installed in resident room #1 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2026
Plan of Correction
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Licensee to remove the latch on the accordion door and all items obstructing the pathway accessing both bedroom doors by POC due date 07/28/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/29/2026 04:33 PM - It Cannot Be Edited


Created By: Julie Florio On 07/27/2026 at 05:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HOME SWEET HOME OF NAPA
FACILITY NUMBER: 286804316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Licensee to submit proof of all of the required initial training hours for S3, S4, and S5 by POC due date 08/28/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2026


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 07/29/2026 04:33 PM - It Cannot Be Edited


Created By: Julie Florio On 07/27/2026 at 05:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HOME SWEET HOME OF NAPA
FACILITY NUMBER: 286804316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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2
3
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Licensee to submit proof of all of the required initial medication training hours for S3, S4, and S5 by POC due date 08/28/2026.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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Based on record review, the licensee did not comply with the section cited above in 2 out of 5 resident files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
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Licensee to submit a copy of the required physician's report for R1 and R2 by POC due date 08/28/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2026


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 07/29/2026 04:33 PM - It Cannot Be Edited


Created By: Julie Florio On 07/27/2026 at 05:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: HOME SWEET HOME OF NAPA
FACILITY NUMBER: 286804316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out 5 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2026
Plan of Correction
1
2
3
4
Licensee to submit a copy of the required proof of ngeative TB results for R1 and R2 by POC due date 08/28/2026.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Julie Florio
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2026


LIC809 (FAS) - (06/04)
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