286800687-4-30-2025-21-AS-JFLO-DG8NWA-20250430104914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800687
Report Date: 04/30/2025
Date Signed: 04/30/2025 10:49:24 AM

Document Has Been Signed on 04/30/2025 10:49 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	CELEBRITY HAVEN II		FACILITY NUMBER:	286800687
ADMINISTRATOR/ DIRECTOR:	FUENTES, ALMA		FACILITY TYPE:	740
ADDRESS:	2212 TROWER AVE.		TELEPHONE:	(707) 251-5722
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY: 6		CENSUS: 0	DATE:	04/30/2025
TYPE OF VISIT:	Office	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Alma Fuentes, Administrator		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

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	On 4/30/2025, at approximately 10:00 AM, an informal meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio and Alma Fuentes, Administrator. The purpose of the informal office meeting was to discuss areas of non-compliance and observed concerns in the of the operation of Celebrity Haven II # 286800687. The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. The legal administrative action process was explained to attendees which is based on areas of non-compliance found during annual visit conducted on April 15, 2025. Items addressed in today's meeting include but are not limited to observed areas of noncompliance in the areas below: - Fire Clearance - Restricted Health Condition - Medication Management -- Administrator to ensure all residents who consume alcohol have a physician's order or an LIC602 which indicates approval in their file and ensure all medications and supplements remain inaccessible to residents in care at all times - Resident Records -- must be complete with required documentation - Personnel Records – must be complete with required documentation Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

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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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: CELEBRITY HAVEN II	FACILITY NUMBER: 286800687
	VISIT DATE: 04/30/2025

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Continued from LIC809...

- First Aid Requirements – Administrator to ensure that all staff have proof of current First Aid given by an American Red Cross provider
- Buildings and grounds

Administrator provided the Department the following documents during today's office meeting:
- Proof of current first aid certification for each staff member
- Updated facility sketch to initiate fire inspection of the converted bedroom and two trailers on the property

LPA Advised the following documents shall be submitted to the Department within 30 days of this meeting:
- Self-certification that all staff records are complete per regulation
- Self-certification that all resident records are complete per regulation

Licensing staff discussed Technical Support Program (TSP) that offers advice, guidance, a review of facility operation, discusses best practice, and required regulation/HSC compliance. Licensee agreed to reach out to the Department if they would like to utilize the TSP assistance benefit in the future.

Failure to submit any of the above requested documentation may result in the Department seeking further action.

No deficiencies were cited during today's office meeting.

Exit interview conducted with Administrator 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: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC809 (FAS) - (06/04)

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