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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803936
Report Date: 11/05/2024
Date Signed: 11/05/2024 05:20:57 PM

Document Has Been Signed on 11/05/2024 05:20 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:NAPA-SONOMA QUALITY CARE HOME LLCFACILITY NUMBER:
496803936
ADMINISTRATOR/
DIRECTOR:		TAPNIO, RYANNEFACILITY TYPE:
740
ADDRESS:4990 FILAMENT CIRCLETELEPHONE:
(707) 595-3766
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY: 6CENSUS: 5DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Rhodora Parino-CaregiverTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Alviso, conduct a Required- 1 Year inspection and met with caregiver Rhodora Parino. Caregiver contacted Administrator Ryanne Tapnio to notify them of LPA's arrival to the facility. Administrator arrived to meet with the LPA.

Facility has a required infection control plan. Facility has a required emergency disaster plan. Facility has an approved hospice waiver for two (2) residents. There is an approved plan of dementia care. Fire clearance is approved for six (6) non-ambulatory, of which one may be bedridden.
LPA toured the facility with the Administrator. Facility was observed by the LPA to be clean and orderly during the inspection.

The annual will be completed at a later date. The following deficiency was observed during today's inspection:

LPA observed a resident room that had some facility items stored in it, these are not the resident's personal belongings. LPA obtained pictures. LPA observed a compact refrigerator for facility resident medications.
LPA observed facility linens stored in the cabinets that are in the residents room. Per interviews with staff these are linens that belong to the facility. There are other facility items stored in the glass cabinets that are facility belongings. The LPA has discussed this with the Administrator in the past, including during prelicensing inspection, which was a change of ownership. Administrator stated their understanding of the above. This deficiency will be cited, 87307(a) Personal Accommodations and Services- Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, who reside in the facility, see LIC809D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator Ryanne Tapnio. Appeal Rights Provided to the Administrator.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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Document Has Been Signed on 11/05/2024 05:20 PM - It Cannot Be Edited


Created By: Dina Alviso On 11/05/2024 at 04:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAPA-SONOMA QUALITY CARE HOME LLC
FACILITY NUMBER: 496803936

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2024
Section Cited

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87307(a) Personal Accommodations and Services- Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, who reside in the facility. This requirement was not met as evidenced by:
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LPA observed a resident room that had some facility items stored in it, these are not the resident's personal belongings. LPA obtained pictures. LPA observed a compact refrigerator for facility resident medications. LPA observed facility linens stored in the cabinets that are in the residents room. Per interviews with staff these are linens that belong to the facility. There are other facility items stored in the glass cabinets that are facility belongings. This is a risk to resident's personal rights.
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Submit photos of resident's R1's room cleared of all facility items, and the refrigerator. Include a written self certification letter of understanding that R1's room and no other resident room is to be used for facility storage. POC due 11/18/24.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


LIC809 (FAS) - (06/04)
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