<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803582
Report Date: 03/15/2022
Date Signed: 03/15/2022 12:35:35 PM


Document Has Been Signed on 03/15/2022 12:35 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:WINE COUNTRY SENIOR LIVING, INC.FACILITY NUMBER:
496803582
ADMINISTRATOR:PATEL, DHARMISTHABENFACILITY TYPE:
740
ADDRESS:1879 ALAN DRIVETELEPHONE:
(707) 665-5624
CITY:PENNGROVESTATE: CAZIP CODE:
94951
CAPACITY:10CENSUS: 7DATE:
03/15/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Dharmi Patel - AdministratorTIME COMPLETED:
12:31 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 case management and met with Dharmi Patel - administrator. The purpose of the case management visit was to obtain additional information regarding incident report & SOC 341 Suspect Abuse that occurred on March 9, 2022 for resident R1 - facility reported to the Department on the same day.

LPA interviewed Dharmi Patel administrator & resident R1, acquired more information and documentation. Per facility administrator, resident’s R1 family member was visiting and learned that there were checks missing from checkbook. Facility has contacted police and family member has been able to acquire documentation from the bank. Department is requesting the following by Friday March 18, 2022:
· Police name and number to contact w/ case number.
· List of telephone numbers for all facility staff.
· List of staff that has worked at facility during the year of 2021.
· Updated copy of SOC 341.
. Careplan for resident R1.

In addition, during file review LPA learned that resident R1 was admitted to the facility on 5/22/2018 and has no pre-assessment or careplan on file except for careplan after admission under hospice care on 5/21/2021. (LIC 809-D) Facility licensee stated that she has in her computer, but would not be able to provide to LPA during this visit.

Appeal of Rights Given.
The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
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 2


Document Has Been Signed on 03/15/2022 12:35 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2022
Section Cited

1
2
3
4
5
6
7
 Each resident's record shall contain at least the following information:The admission agreement and pre-admission appraisal...This requirement isn't met as evidenced by:Based on file review & interview, licensee
8
9
10
11
12
13
14
didnt comply w/section cited above in 1 out 1 resident pre-admission appraisal & careplans missing on file since admission on 5/22/18 which poses/posed a potential health,safetyorpersonal rights risk to persons in care.
8
9
10
11
12
13
14
to review during a visit. Facility to submit a self certification that residents files have pre-ssess and careplans according w/admissions agreement, residents needs, and Title 22 Regs by POC date of 3/29/2022.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2