496803340-7-22-2021-21-AS-EGCS-C56SRD-20210722140609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803340
Report Date: 07/22/2021
Date Signed: 07/22/2021 02:06:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	NAZARETH AGUA CALIENTE VILLA		FACILITY NUMBER:	496803340
ADMINISTRATOR:	RAGLAND, SHANTI		FACILITY TYPE:	740
ADDRESS:	17250 VAILETTI		TELEPHONE:	(707) 996-6100
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	45	CENSUS: 24	DATE:	07/22/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Administrator, Shanti Ragland		TIME COMPLETED:	02:20 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) Erik Gonzalez Campos arrived unannounced to conduct an Annual inspection at approximately 12:30 PM, and met with administrator Shanti Ragland. The inspection is focused on the Infection Control procedures and practices of this facility. At primary entrance LPA observed visitor sign-in sheet and screening forms. LPA conducted walk through of the facility with administrator and observed COVID postings throughout. Mitigation plan was received and reviewed during visit by LPA. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Staff have completed Personal Protective Equipment (PPE) and infection control training through Kaiser as well as local public health. Staff have not been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census, residents could isolate in their own rooms if they became ill. There is also a designated isolation wing with two isolation rooms ready if necessary. LPA confirmed administrator has necessary PPE and supplies to support a resident in isolation. Residents' emergency contact information has been updated and administrator confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents. A 30 day supply of medications are stored in locked medicine room making them inaccessible to residents. The facility has a sufficient supply of Personal Protective Equipment (PPE) located in training room. Exit alarms on exit doors were working properly. Facility has a vaccination rate greater than 70 percent for staff and residents but is continuing to surveillance test. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: NAZARETH AGUA CALIENTE VILLA	FACILITY NUMBER: 496803340
	VISIT DATE: 07/22/2021

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Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing. Indoor visits are by appointment only and currently limited to 15 minutes. Outdoor visits are conducted on the outdoor patio area with no time restrictions.

Administrator indicated that while residents are monitored daily for COVID symptoms, their temperatures are not documented. LPA to seek further clarification regarding guidelines.

Administrator also indicated that while staff and visitors are screened for symptoms, their temperatures are not taken. LPA provided guidance to review PIN 21-17.2 and resume screening for temperatures.

LPA requested current copy of liability insurance during visit.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC809 (FAS) - (06/04)

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