<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803879
Report Date: 11/04/2022
Date Signed: 11/04/2022 03:02:50 PM

Document Has Been Signed on 11/04/2022 03:02 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: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:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Lead Staff, Gamilla RamosTIME COMPLETED:
03:05 PM
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
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 11/04/2022 to conduct a required - 1 year inspection. LPA was greeted and screened by staff. Administrator, Krystal Smith was not available. LPA met with Gamilla Ramos. This inspection is focused on the infection control practices and procedures of this facility.

LPA toured building and grounds which were found to be clean and in good repair. Facility currently has six residents. The amount of fresh and non-perishable food was within regulation. Fire extinguishers inspected were charged and current. Toxins were locked and secured. Medications were centrally stored and locked. Carbon monoxide and smoke detectors were present and operational. Walkways were cleared and unobstructed. High touch surface areas are disinfected daily. LPA observed COVID postings at the front entrance. Staff and residents are all fully vaccinated. Facility has necessary Personal Protective Equipment to support a resident in isolation. LPA and staff discussed resident/staff record keeping. Staff have been given infection control training.

LPA requested the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 Designation of Facility Responsibility
Liability Insurance
LIC 610 Emergency Disaster Plan
LIC 9020 Resident Roster
LIC 500 Personnel Report

No deficiencies observed during today's inspection. Exit interview conducted with Gamilla Ramos and a copy of this report emailed to the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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 1