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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804041
Report Date: 10/14/2022
Date Signed: 10/14/2022 01:49:44 PM

Document Has Been Signed on 10/14/2022 01:49 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: 28DATE:
10/14/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Executive Director, Emil De GuzmanTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Post Licensing Inspection. LPA met with executive director, Emil De Guzman.

LPA toured the building and grounds with director which were clean and in good repair. Walkways and exits were clear and unobstructed. There are currently 28 residents in care. Medications were locked and inaccessible in medication room. Toxins were locked and inaccessible. LPA observed sufficient perishable and non perishable food. Fir extinguishers were last inspected April 8, 2022. Carbon monoxide detectors were present and functioning. There is a sufficient supply of hygiene products and linens on hand for resident use. LPA reviewed Personnel Policies, Abuse Reporting Procedures, In-Service Training, Medication Procedures, Addendums to Admission Agreements, and Resident Records with executive director during today's inspection. During the inspection LPA reviewed resident file regarding eviction on 08/24/2022.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this inspection:

LIC500 Personnel Report
LIC308 Designation of Responsibility
LIC610 Disaster Plan
Evidence of Liability Insurance
LIC200 Application for Administrator Change
Administrator's Certificate
Minutes of Meeting Appointing Administrator

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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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