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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803936
Report Date: 10/17/2023
Date Signed: 10/17/2023 07:08:51 PM


Document Has Been Signed on 10/17/2023 07:08 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:NAPA-SONOMA QUALITY CARE HOME LLCFACILITY NUMBER:
496803936
ADMINISTRATOR:TAPNIO, RYANNEFACILITY TYPE:
740
ADDRESS:4990 FILAMENT CIRCLETELEPHONE:
(707) 595-3766
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 5DATE:
10/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Joy Montes-CaregiverTIME COMPLETED:
07:08 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso, conduct a Required- 1 Year inspection and met with Lead caregiver Joy Montes. LPA observed another caregiver working, Paul Montes. Administrator Ryanne Tapnio was not available to meet with the LPA.

Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved hospice waiver for two (2) residents. There is an approved plan of dementia care. Fire clearance is approved for six (6) non-ambulatory.

The LPA reviewed five (5) client files. The LPA reviewed six (6) staff files. All staff had criminal record clearance as required.

LPA toured the facility with caregiver Joy. Hot water was checked at 108.5 Fahrenheit. Fire extinguishers (two) were serviced and tagged as required-expires 10/30/23. The facility was clean and orderly. Carbon monoxide detector was working properly. Exit alarms were working properly. Food supply was sufficient. Sufficient supply of cleaners, paper products, and hygiene products. Sufficient supply of personal protective equipment (PPE). Bathrooms were clean and orderly: Bathrooms had grab bars and non-slip mats/flooring for resident use.

Licensee/Administrator to submit the following documents by 11/17/23:
LIC 308 Designation of Administrative Responsibility
LIC 500 Personnel Report
LIC 9020 Register of Residents
LIC 610 E Emergency Disaster Plan for RCFE -reviewed & updated as needed
Copy of current Liability Insurance
Infection Control Plan-reviewed & updated as needed
LIC400 Handling of Client Cash Resources, include copy of surety bond.

LPA observed the following deficiencies:
LPA observed vegetables in the refrigerator that were no longer fresh, and of good quality, some were old and rotting. LPA obtained pictures.
Continued on LIC809C...
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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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Document Has Been Signed on 10/17/2023 07:08 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: NAPA-SONOMA QUALITY CARE HOME LLC
FACILITY NUMBER: 496803936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed vegetables in the refrigerator that were no longer fresh, and of good quality, some were old and rotting. LPA obtained pictures], the licensee did not comply with the section cited above in storage of food maintaining quality and nutritive values, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
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Licensee to ensure they go through both refrigerators, and remove and discard any food items, including vegetables, that are old, rotting, and no longer safe for residents to consume; Also submit a plan on maintaining the food items ensuring that food is fresh, of good quality and nutritive value for thr residents. Plan of correction due 10/19/23.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental 87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed the large cabinet with all resident medications to not be locked, and a metal box in the refrigerator with medications that was unlocked, making all medications accessible to residents, and to staff/individuals that should not have access to the medications., the licensee did not comply with the section cited above,which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2023
Plan of Correction
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Licensee to ensure all medications are locked up and inaccessible to residents in care, any visitors to the facility, and to staff not trained to handle medications. POC due 10/19/23
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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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: NAPA-SONOMA QUALITY CARE HOME LLC
FACILITY NUMBER: 496803936
VISIT DATE: 10/17/2023
NARRATIVE
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This deficiency will be cited, General Food Service Requirements 87555(b)(8)- All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained, see LIC809D.

LPA observed the large cabinet with all resident medications to not be locked, and a metal box in the refrigerator with medications that was unlocked, making all medications accessible to residents, and to staff/individuals that should not have access to the medications. This deficiency will be cited, Incidental Medical and Dental 87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D.

Based on LPA's record review, staff #3 lacks first aid certification. This deficiency will be cited,Personnel Requirements-General 87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D.



LPA observed a resident room and bathroom with garbage cans without tight fitting lids, one of the garbage cans had a dirty diaper and other items used in cleaning and changing the resident. This deficiency will be cited, Maintenance and Operation 87303(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors, see LIC809D.

Per LPA's record review, staff #2 and #3 lack initial training hours, This deficiency will be cited, as required by H&S Code 1569.625(b)(1)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, see LIC809D.

Continued on LIC809C...

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2023 07:08 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: NAPA-SONOMA QUALITY CARE HOME LLC
FACILITY NUMBER: 496803936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's revord review, staff #3 lacks first aid certification, the licensee did not comply with the section cited above in 1t] out of 4 [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee to ensure that all staff have required first aid training; Submit copy of S3's first aid certification to the Licensing Department by POC due date of 10/20/23.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation 87303(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
LPA observed a resident room and bathroom with garbage cans without tight fitting lids, one of the garbage cans had a dirty diaper and other items used in cleaning and changing the resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed a resident room and bathroom with garbage cans without tight fitting lids, one of the garbage cans had a dirty diaper and other items used in cleaning and changing the resident. , the licensee did not comply with the section cited above , which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/20/2023
Plan of Correction
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Licensee to ensure all facility garbage cans have tight fitting lids to ensure the facility is free from odors, including urine/feces odors, ensuring the facility is sanitary. Submit plan of correction by POC 10/20/23.
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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2023 07:08 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: NAPA-SONOMA QUALITY CARE HOME LLC
FACILITY NUMBER: 496803936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.61
1569.625(b)(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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Based on LPA's record reviews, S2 and S3 lack intitial training as required by H&S Code, 40 Hrs, with 20 initial hrs prior to working independently, S2 & S3 on shift only during the inspection, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2023
Plan of Correction
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Licensee to ensure all staff , S2, and S3, obtain required initial 40 hour training, the initial 20 hour training as required by H&S to be completed by 11/3/23. Submit proof of the 20 hrs required trainings having been completed, and the plan on ensuring the remainder of the 40 hrs is completed timely. POC due date of 11/03/23.

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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2023 07:08 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: NAPA-SONOMA QUALITY CARE HOME LLC
FACILITY NUMBER: 496803936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records, Staff #2 & #3 lack a health screening report, including TB test and results. the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2023
Plan of Correction
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Licensee to ensure that staff #2 and #3 obtain a health screening, including a TB test, and results, by 10/24/23. Submit copies of the documents by POC due 10/24/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
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: NAPA-SONOMA QUALITY CARE HOME LLC
FACILITY NUMBER: 496803936
VISIT DATE: 10/17/2023
NARRATIVE
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Based on review of records, Staff #2 & #3 lack a health screening report, including TB test and results87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.

Per file review and observations, the facility has retained a bedridden resident, R1, but does not have the proper fire clearance as required. This deficiency will be cited, (c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a), see LIC809D.

Deficiencies 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.

Appeal rights provided to lead caregiver Joy Montes. Exit interview conducted with caregiver Joy Montes All documents left with Caregiver JM for Administrator Ryanne Tapnio.

SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 10/17/2023 07:08 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: NAPA-SONOMA QUALITY CARE HOME LLC
FACILITY NUMBER: 496803936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per file review and observations, the facility has retained a bedridden resident, R1, but does not have the proper fire clearance as required], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty will be assessed in the amount of $500, see LIC421IM.
POC Due Date: 10/18/2023
Plan of Correction
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Licensee tto ensure that residents admitted and residents retained are within the fire clearance approval. Licensee to submit updated facility sketch shwoing all resident rooms and current ambulatory/nonambulatory/bedridden status, submit an LIC200 completed, with the facility sketch by 10/18/23. The Department will request a fire clearance inspection by Local Fire Department. If not able to obtain and/or you don't want to try to obtain a new fire clearance, please submit plan of how you will bring the facility into compliance. POC due 10/19/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:
DATE: 10/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/17/2023
LIC809 (FAS) - (06/04)
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