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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803879
Report Date: 01/04/2022
Date Signed: 01/04/2022 02:31:42 PM

Document Has Been Signed on 01/04/2022 02:31 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ASSISTED LIVING OF NAPA VALLEY-SHERMANFACILITY NUMBER:
286803879
ADMINISTRATOR:SMITH, KRYSTALFACILITY TYPE:
740
ADDRESS:1460 SHERMAN AVETELEPHONE:
(707) 312-2971
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 6DATE:
01/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Glenda Santos, StaffTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct an Required- 1 year annual inspection and met with staff, Glenda Santos. The annual inspection was focused on the Infection Control procedures and practices. LPA conducted risk assessment with staff.

LPA conducted a tour of the facility with staff, Glenda Santos. Fire Extinguishers were found to be last charged on October 14, 2021. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. There was sufficient amount of supply for both perishable and nonperishable foods. Facility smoke detectors and carbon monoxide were found to be functioning properly at the time of the visit.

LPA observed COVID-19 precaution postings but asked facility to add more postings. LPA advised facility to take temperature for all staff, visitors and residents coming in to facility since LPAs temperature was not taken when LPA arrived to facility. Facility had sign-in sheet with screening questions at facility entrance. Resident's temperatures are taken once a day and documented. Staff clean and disinfect the facility at least once daily. Staff have completed training on PPE use but will have staff train on infection prevention, symptoms, transmission. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was reviewed by the California Department of Social Services.

Exit interview conducted with staff, Glenda Santos whose signature on this document confirms receipt.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Karen Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2022
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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