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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286804248
Report Date: 04/10/2025
Date Signed: 05/02/2025 09:26:00 AM

Document Has Been Signed on 05/02/2025 09:26 AM - 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:VINE HILL SENIOR LIVINGFACILITY NUMBER:
286804248
ADMINISTRATOR/
DIRECTOR:		UY, NANCYFACILITY TYPE:
740
ADDRESS:2529 VINE HILL COURTTELEPHONE:
(415) 846-4133
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 6DATE:
04/10/2025
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Safir Rezzoug, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 04/10/2025, at approximately 1:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced at the facility to conduct a post-licensing inspection and met with Safir Rezzoug, Licensee. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care, all of whom were present during today's inspection. Facility has a Dementia Care Plan, a Hospice waiver for four (4), and is approved for four (4) non-ambulatory residents.

At approximately 1:45 PM, LPA initiated a tour of the facility with Licensee and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured at 132 degrees F which in outside the allowable range of 105 to 120 degrees F per Title 22 regulations. Licensee agreed to turn down the water heater and track the facility's water temperatures over the next 10-days to ensure the facility has been brought back into compliance with regulation. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA advised Licensee to increase the amount of fresh fruit and vegetable available to residents in the facility. Licensee agreed. LPA informed Licensee that no staff shall sleep in the garage area of the facility as it is not a cleared space for staff sleeping quarters. Licensee conveyed understanding of this and agreed to comply. LPA advised Licensee that the required personal right poster and a copy of the current administrator's active certificate shall be posted in a conspicuous area of the facility. Licensee agreed to bring the facility into compliance with regulation.

At approximately 2:00 PM, LPA began file review. LPA reviewed five (5) staff files and one (1) resident file. LPA observed three (3) of five (5) staff files missing proof of initial 40 hours of training, four of four staff file missing proof of initial medication training, and one (1) staff file missing proof of first aid training.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: VINE HILL SENIOR LIVING
FACILITY NUMBER: 286804248
VISIT DATE: 04/10/2025
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Continued from LIC809...

LPA observed Resident 1 (R1) missing the required annual physician's repot and updated appraisal needs and services plan. LPA informed Licensee that all required forms shall be signed by staff, resident, or responsible party to remain in compliance with regulation.

LPA will return at later date to complete this post-licensing inspection and may issue citations at that time.

Licensee informed LPA that they would like to change the facility administrator to himself.

Required Change of Administrator Documents:

  • LIC 308 (Designation of Facility Responsibility)
  • Active and Current Administrator Certificate
  • First Aid Certificate
  • LIC 500 (Personnel Report)
  • LIC 501 (Personnel Record)
  • LIC 503 (Health Screening Report - personnel)
  • Proof of Negative TB test
  • LIC 9182 (Criminal Record Exemption Transfer Request)
  • LIC 508 (Criminal Record Statement)
  • Copy of Driver's License or Passport that is not expired
  • Statement signed by Licensee requesting Change of Administrator

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
  • Proof of Liability Insurance (Updated)
  • LIC308 - Designation of Facility Responsibility
  • Current Administrator Certificate

No deficiencies cited during today's inspection.

Exit interview conducted with Licensee, whose signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Julie Florio
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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