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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804053
Report Date: 02/04/2025
Date Signed: 02/04/2025 01:02:50 PM

Document Has Been Signed on 02/04/2025 01:02 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NAZARETH ROSE GARDEN OF NAPAFACILITY NUMBER:
286804053
ADMINISTRATOR/
DIRECTOR:		RAGLAND, SHANTIFACILITY TYPE:
740
ADDRESS:903 SARATOGA DRIVETELEPHONE:
(707) 252-7488
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY: 44CENSUS: 31DATE:
02/04/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Shanti SubbaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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At approximately 09:15AM, LPAs Stevenson and Arnhold,LPA) made an unannounced annual required continuation inspection of this licensed senior care facility. LPAs met with administrator Shanti Subba and reviewed records. At approximately 9:45am LPAs reviewed 10 of 31 resident records and which were found to be organized and complete. 10 of 10 resident records contained current and signed admission agreements and physician's orders on file. Medication records are thorough and contained physician's orders for each resident.
At approximately 11:00AM, LPAs Stevenson and Arnhold reviewed 5 staff records. Evidence of completed annual training and current first aid and CPR training were on file.

At approximately 12:15 PM, LPAs reviewed medication procedures of the facility and found them to be in compliance with title 22 regulations.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
Evidence of Liability Insurance


No citations issued during this visit
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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