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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803675
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:08:03 PM

Document Has Been Signed on 02/15/2024 01:08 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
SANTA ROSA RO, 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:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Christine ArnkeTIME COMPLETED:
01:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:15AM to conduct an Annual Required inspection and was greeted by staff. LPA and staff discussed the purpose of the visit. Administrator, Christine Arnke arrived shortly after.

LPA and Administrator initiated a walk through of facility at approximately 9:30AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 115 and 116 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water is rotated and stored in the hallway closet.

LPA observed an ADU in the backyard. Per conversation with Administrator, only the Owner/Administrator stays in the house when they are in town. LPA and Administrator discussed that only people who have been background cleared and are associated to this facility are able to stay in the ADU. In addition, LPA and Administrator discussed that Community Care Licensing (CCL) must be notified prior to any construction on facility grounds.

Fire extinguishers were last serviced 10/06/2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 01/19/2024.

Continued on LIC 809-C
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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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: ASSISTED LIVING OF NAPA VALLEY-HAMILTON
FACILITY NUMBER: 286803675
VISIT DATE: 02/15/2024
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Continued from LIC809

Five staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administrator certificate for Administrator, Christine Arnke (6058377740) expired on 08/08/2023 and is on the pending list for renewal. Medications and medication records were reviewed.

During medication review, LPA observed that (Resident 1's) R1's Centrally Stored Medication Log reflected a start date of a new bubble pack with the date 02/07/2024. However, Resident 1 moved into facility on 02/10/2024. Should the medications have begun on 02/07/2024, there would be a total of 7 medications administered from the bubble pack. In addition, facility keeps a Medication Administration Record that indicated that medications were successfully administered to R1, however the medication bubble pack reflected that less than 7 days of medications were successfully administered. Centrally Stored Medication Log was not accurate.

LPA is requesting the following to be submitted to CCL by 03/15/2024:
Permits for ADU
Updated facility sketch reflecting ADU on property
Proof that ADU was cleared by Fire Department
LIC308 Designation of Facility Responsibility
LIC 500 Personnel Report
Liability Insurance
LIC 9020 Resident Roster

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.

Exit interview conducted. Copy of report, LIC809D, and appeal rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Helena Rummonds
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/15/2024 01:08 PM - It Cannot Be Edited


Created By: Helena Rummonds On 02/15/2024 at 12:40 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: ASSISTED LIVING OF NAPA VALLEY-HAMILTON
FACILITY NUMBER: 286803675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above by not ensuring that the Centrally Stored Medication log was not accurate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2024
Plan of Correction
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Administrator agrees to audit Centrally Stored Medication logs and their corresponding medications to ensure that they are accurate. Adminstrator agrees to submit a plan addressing how to avoid record keeping errors in the future.
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:Bethany Moellers
LICENSING EVALUATOR NAME:Helena Rummonds
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
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