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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
286802049
Report Date:
09/27/2024
Date Signed:
09/27/2024 12:29:18 PM
Document Has Been Signed on
09/27/2024 12:29 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:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
ADMINISTRATOR/
DIRECTOR:
ROA, FRANCISCO
FACILITY TYPE:
740
ADDRESS:
2541 VINTAGE STREET
TELEPHONE:
(707) 265-8652
CITY:
NAPA
STATE:
CA
ZIP CODE:
94558
CAPACITY:
6
CENSUS:
3
DATE:
09/27/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:
Gerry Ofiza
TIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold made an unannounced annual required inspection of this licensed senior care facility. LPA met with caregiver Gerry Ofiza. At approximately 9:30AM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. LPA observed facility did not have resident rights posted. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored and not accessible. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. LPA observed medication in small cups in a cupboard in the kitchen. The door to the cupboard was not secured.
At approximately 10:00AM, LPA reviewed 3 of 3 resident records and found 3 of 3 residents did not have current care plans. 3 of 3 records contained current and signed admission agreements. There are currently no residents receiving Hospice services, however, 1 of 3 recently graduated from Hospice and there was no hospice care plan on file.
At approximately 11:00AM, LPA reviewed 4 staff files. LPA did not find evidence of completed annual training in 4 of 4 files. LPA observed 3 of 4 staff had current First aid/CPR certification.
Continued on LIC 809-C...
SUPERVISORS NAME
:
Bethany Moellers
LICENSING EVALUATOR NAME
:
Christopher Arnhold
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/27/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2024
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
7
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:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
VISIT DATE:
09/27/2024
NARRATIVE
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At approximately 11:30AM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Staff were not able to explain what to do in an emergency. Facility has not conducted and documented a disaster drill.
Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
Current Lease Agreement or evidence of Control of Property
LIC308- Designation of Responsibility
LIC500- Personnel Report
LIC610E- Disaster Plan
Evidence of Liability Insurance
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with
Gerry Ofiza
and Appeal rights were given.
SUPERVISORS NAME
:
Bethany Moellers
LICENSING EVALUATOR NAME
:
Christopher Arnhold
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2024
LIC809
(FAS) - (06/04)
Page:
2
of
7
Document Has Been Signed on
09/27/2024 12:29 PM
- It Cannot Be Edited
Created By:
Christopher Arnhold
On
09/27/2024
at
12:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Prepared medication was stored in an unsecured cupboard in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/27/2024
Plan of Correction
1
2
3
4
Medication was removed from the cupboard and stored in the secured medication area. POC cleared during visit.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed prepared medication for resident no longer living in the facility, in an an unsecured cupboard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/27/2024
Plan of Correction
1
2
3
4
Medication was removed and secured with the remainder of former residents medication awaiting destruction. POC cleared during visit.
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 Moellers
LICENSING EVALUATOR NAME:
Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE:
09/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2024
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
09/27/2024 12:29 PM
- It Cannot Be Edited
Created By:
Christopher Arnhold
On
09/27/2024
at
12:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. Nighttime staff was not familiar with facility emergency procedures which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2024
Plan of Correction
1
2
3
4
Licensee to ensure facility staff are familiar with emergency procedures. Licensee to conduct training with all staff on emergency procedures and submit evidence of completed training to CCL by POC date of 10/11/2024.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff records. There was no evidence of completed annual training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2024
Plan of Correction
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2
3
4
Licensee to ensure all staff complete the required 20 hours of annual training. Licensee to submit written plan detailing what training staff will be taking and when the training will take place. Written plan to be submitted to CCL by POC date of 10/11/2024.
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 Moellers
LICENSING EVALUATOR NAME:
Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE:
09/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2024
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
09/27/2024 12:29 PM
- It Cannot Be Edited
Created By:
Christopher Arnhold
On
09/27/2024
at
12:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(1)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. Facility did not have resident rights posted. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2024
Plan of Correction
1
2
3
4
Licensee to post resident rights in a prominent location inside the facility. Licensee will submit self certification that the poster has been posted by POC date of 10/11/2024.
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above. Facility does not have a dedicated device for resident use which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2024
Plan of Correction
1
2
3
4
Licensee will submit self certification that a device has been provided and is dedicated for resident use. Self certification to be submitted by POC date of 10/11/2024.
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 Moellers
LICENSING EVALUATOR NAME:
Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE:
09/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2024
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
09/27/2024 12:29 PM
- It Cannot Be Edited
Created By:
Christopher Arnhold
On
09/27/2024
at
12:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 of 3 resident files. Resident appraisals were either not updated or not completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2024
Plan of Correction
1
2
3
4
Licensee to complete resident appraisals per regulation. Self certification that appraisals have been completed shall be submitted to CCL by POC date of 10/11/2024.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. Facility has not completed or documented a disaster drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2024
Plan of Correction
1
2
3
4
Licensee to conduct and document emergency drills at least quarterly. Self certification that a drill has been completed and documented shall be submitted to CCL by POC date of 10/11/2024.
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 Moellers
LICENSING EVALUATOR NAME:
Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE:
09/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2024
LIC809
(FAS) - (06/04)
Page:
6
of
7
Document Has Been Signed on
09/27/2024 12:29 PM
- It Cannot Be Edited
Created By:
Christopher Arnhold
On
09/27/2024
at
12:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/27/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 of 3 resident files. Resident graduated Hospice, but there was no Hospice care plan on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/11/2024
Plan of Correction
1
2
3
4
Licensee shall review regulation 87632 and 87633 and shall submit self certification they understand the requirements for caring for residents receiving Hospice services. Self certification to be submitted by POC date of 10/11/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Moellers
LICENSING EVALUATOR NAME:
Christopher Arnhold
LICENSING EVALUATOR SIGNATURE:
DATE:
09/27/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/27/2024
LIC809
(FAS) - (06/04)
Page:
7
of
7