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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803675
Report Date: 03/23/2022
Date Signed: 03/23/2022 10:59:11 AM

Document Has Been Signed on 03/23/2022 10:59 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:ASSISTED LIVING OF NAPA VALLEY-HAMILTONFACILITY NUMBER:
286803675
ADMINISTRATOR:SMITH, KRYSTALFACILITY TYPE:
740
ADDRESS:3100 HAMILTON STREETTELEPHONE:
(707) 637-4562
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY: 6CENSUS: 6DATE:
03/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:28 AM
MET WITH:Care Giver, Renie Ragojos
Administrator, Christine Arnke		TIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived at Assisted Living of Napa Valley-Hamilton unannounced for the purpose of conducting a Required-1 year inspection. LPA was granted access into the facility by Care Giver, Renie Ragojos. During the initial entry at the facility at 09:30 AM, LPA observed this particular Care Giver not wearing a Facial Covering (See LIC 809D). Administrator, Christine Arnke arrived 20 minutes later.

LPA toured the facility with the Administrator, LPA observed the facility to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. 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 at the time of the visit. Menus are available. There are special provisions made for individuals with special dietary needs. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms in resident’s rooms have a towel and soap. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers were inspected on 11/2021. First Aid kit was appropriate at the time of the inspection. Smoke detectors were tested and found to be in working order. Carbon Monoxide detectors were present and found to be operational during the inspection. Fire Alarm Pull system is in place. Medication is centrally stored and secured. The facility serves residents with dementia and has a plan of operation for care and programming. Facility understands that all beds should be outfitted with mattress pads as per Title 22 Regulations # 87307.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2022
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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Document Has Been Signed on 03/23/2022 10:59 AM - It Cannot Be Edited


Created By: Farhaan Sarangi On 03/23/2022 at 09:53 AM
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: ASSISTED LIVING OF NAPA VALLEY-HAMILTON
FACILITY NUMBER: 286803675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities :
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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On 03/23/2022, Care giver failed to protect the personal rights of residents in care and engaged in conduct inimical to the health, welfare, and safety of residents in care, in that facility staff, Renie Ragojos failed to wear face coverings while providing care and supervision to residents in care, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.
POC Due Date: 03/24/2022
Plan of Correction
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Licensee and/or Administrator shall review the Mitigation Plan with ALL staff and provide proof via a sign-in sheet along with a statement on how future compliance will be met.
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 DeBenedetti
LICENSING EVALUATOR NAME:Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022


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: ASSISTED LIVING OF NAPA VALLEY-HAMILTON
FACILITY NUMBER: 286803675
VISIT DATE: 03/23/2022
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LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drill last conducted on February 20, 2022. Facility has PPE supply stored in storage room. Facility was N95 Fit tested on January 2022 by Napa County Public Health.

LPA requested the following documents be sent to CCL:

LIC 308 Designated Facility Responsibility
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 Administrator Certificate(s)
Copy of Certificate of Liability Insurance

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 were provided. Administrator requested a copy sent via email as well.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC809 (FAS) - (06/04)
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