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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804041
Report Date: 07/25/2024
Date Signed: 07/25/2024 01:17:11 PM

Document Has Been Signed on 07/25/2024 01:17 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:NAZARETH CLASSIC CARE OF NAPA INCFACILITY NUMBER:
286804041
ADMINISTRATOR/
DIRECTOR:
MINERVA VILLEGASFACILITY TYPE:
740
ADDRESS:2465 REDWOOD ROADTELEPHONE:
(510) 468-1909
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 46CENSUS: 24DATE:
07/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Administrator, Minerva VillegasTIME VISIT/
INSPECTION COMPLETED:
01:31 PM
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Licensing Program Analyst (LPA) Jacky Macias arrived unannounced at approximately 9:20am to conduct an Annual Required inspection and was greeted by staff. Administrator Minerva Villegas arrived shortly after. LPA discussed the purpose of the visit to Administrator.

Hospice care waiver approved for ten(10) residents. Facility has an approved dementia plan of operation. Facility has a required Infection Control Plan, which is part of the facility's plan of operation. Fire clearance approval is for 46 non-ambulatory residents, of which 10 may be bedridden.

At approximately 10:00am, LPA and Administrator initiated a tour of the facility which included resident rooms, kitchen, food storage, dining room and common area used by residents. Facility was at a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in various restroom sinks accessible to residents in care were all within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cleaning supplies are locked in supply closet. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality, stored per regulation. There is also a daily activity schedule for residents. Some of the activities available for residents are: chair exercises, puzzles, coloring, book club, movie night, bingo, arts and crafts, dancing, and karaoke.

Five staff files and five resident files were reviewed and found to be well organized, thorough, and contained all of the required documentation. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Minerva Villegas (7030490740) Exp 10/21/2025.

Medications are centrally stored in a secured room and were reviewed. No deficiencies.

Fire extinguishers were last serviced May 17, 2024. Facility has carbon monoxide detectors and a fire alarm system that is serviced by an outside vendor that was last inspected on May 7, 2024. Most recent fire/disaster drill was conducted 4/10/2024. Administrator to conduct the next fire drill on 7/30/2024.

Continued on LIC809C...
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
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: NAZARETH CLASSIC CARE OF NAPA INC
FACILITY NUMBER: 286804041
VISIT DATE: 07/25/2024
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Continued from LIC809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: 8/54/2024

LIC500- Personnel Report
Liability Insurance
LIC 9020 Register of Residents
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

Exit interview was conducted with Administrator and a copy with given. No deficiencies cited at the time of inspection. Signature on forms confirms receipt of documents...
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jacqueline Macias
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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