496803582-2-25-2022-21-AS-CFGS-CBYLPF-20220225075551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803582
Report Date: 02/24/2022
Date Signed: 02/25/2022 07:56:00 AM

Document Has Been Signed on 02/25/2022 07:56 AM - 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:	WINE COUNTRY SENIOR LIVING, INC.		FACILITY NUMBER:	496803582
ADMINISTRATOR:	PATEL, DHARMISTHABEN		FACILITY TYPE:	740
ADDRESS:	1879 ALAN DRIVE		TELEPHONE:	(707) 665-5624
CITY:	PENNGROVE	STATE: CA	ZIP CODE:	94951
CAPACITY:	10	CENSUS: 6	DATE:	02/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Pamela Lopez - staff		TIME COMPLETED:	12:15 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) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Pamela Lopez. Administrator Dharmisthaben Patel was contacted and arrived during the visit. There were 8 residents with 4 under hospice at facility. Facility has activities planned for residents that are willing to participate during the day. LPA arrived at the facility and had her temperature checked and logged into a log. During facility tour on 2/24/2022 with staff; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 2/2021 at the time of the visit. Sample test of Smoke Detectors & Carbon monoxide detector were found to be operational during this visit. There was a sufficient supply of both perishable and nonperishable foods 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. Facility has no residents' with a special diet at this time. Toxins are stored in a locked cabinet under the kitchen sink, laundry room, and hallway closet. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. LPA conducted a sample inspection of resident’s bedrooms which were found with lighting & appropriate furnishings. Facility hot water temperature in residents' bathroom faucet measured between 114.7 degrees F and 117.5 degrees F in 2 out of 2 faucets within Title 22 acceptable regulations of 105 to 120 degrees F. Disaster drills are being conducted and facility understands that they must be conducted quarterly as per Title 22 Regulations. Infection Control: Facility has submitted a mitigation program plan that has been approved. Posters have been placed throughout of the facility. Facility has a small table outside by entrance door with hand sanitizer available; visitors and staff before coming into work have temperature checked. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

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: WINE COUNTRY SENIOR LIVING, INC.	FACILITY NUMBER: 496803582
	VISIT DATE: 02/24/2022

NARRATIVE

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Facility has PPE supply stored in hallway closet and laundry room. There has been new staff hired and new resident’s admission since COVID. Residents’ medications are stored and locked in a medication closet in the hallway. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors if needed otherwise visitations are conducted in resident’s room. Residents have also available virtual and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and have acquired N-95 fit testing for staff.

In addition, facility has a change of ownership in process. Licensee Mera S. to submit closure documentation needed as stated below no later then 3/3/2022:
* Plan of facility closure. NOTE: In the case of facility being sold to an individual and/or corporation, please include information of individual/corporation in the facility closure plan. Facility will have to remain under
licensee responsibility until new application is approved and facility is licensee to new owner.
• Copy of LAWFULL eviction notices given to residents – eviction notices for facility closure must
be of 60 days Title 22 Regulations #87507 and Health & Safety Code # 1569.682. In addition,
eviction notices must provide residents with location resources of facilities that can be contacted.
* LIC 9020
• Mail or Turn-in person to Community Care Licensing your original license once new license is approved.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 3/3/2022:

LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC809 (FAS) - (06/04)

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