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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804041
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:36:00 PM

Document Has Been Signed on 04/12/2022 03:36 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:NAZARETH CLASSIC CARE OF NAPA INCFACILITY NUMBER:
286804041
ADMINISTRATOR:RAGLAND, SHANTIFACILITY TYPE:
740
ADDRESS:2465 REDWOOD ROADTELEPHONE:
(510) 468-1909
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 46CENSUS: 34DATE:
04/12/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator, Shanti Ragland
Licensee, Bobby T. Singh		TIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Nazareth Classic Care of Napa Inc for the purpose of conducting a Pre-Licensing Inspection due to Change of Ownership. Currently, there is 34 residents in care during this Change of Ownership. Facility is approved for 36 non-ambulatory and 10 bedridden residents. LPA was met at the door by Administrator, Shanti Ragland and was granted access into the facility. New licensee, Bobby T. Singh arrived 14 minutes later to introduce himself and participate in the Pre-Licensing inspection.

LPA toured the building and grounds with the new Licensee. Facility was found to be clean, in good repair and at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. The amount of fresh and nonperishable foods was within regulation. Food stored in the kitchen refrigerators was properly stored as per regulations at the time of this inspection. Emergency Supplies are locked in a closet in hallway 2. Toxins are stored in a locked closet in the hallway 3. Hygiene supplies are locked in the Nursing Supply closet in hallway 1. A sample tour of 3 empty facility rooms were inspected, water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers were last inspected on April 2022. First Aid kit was found to be appropriate during the inspection. Smoke detectors are hardwired into the fire suppression system. Carbon Monoxide detectors were present and were found to be operational during the inspection. Egress Doors were tested and found to be operational during the inspection. Medication is centrally stored and secured. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. All bedrooms have lighting & appropriate furnishings. Resident’s beds were outfitted with mattress pads as required by Title 22 Regulations # 87307.

(Report continued on LIC 809C)
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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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: NAZARETH CLASSIC CARE OF NAPA INC
FACILITY NUMBER: 286804041
VISIT DATE: 04/12/2022
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Emergency Disaster Plan was discussed and COVID-19 Mitigation Plan was discussed and approved during the Pre-Licensing Inspection. LPA requested the following documents during the Pre-Licensing inspection:

-Program Plan of Operation
-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 Certificate of Liability Insurance

Component III was completed with the Licensee on April 12, 2022 during the Pre-Licensing inspection.

No deficiencies were observed during today's Pre-Licensing inspection. Exit interview was conducted and a copy of this report was emailed to the facility Administrator and new Licensee.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC809 (FAS) - (06/04)
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