Celebrity Haven II

Type of visit: Required - 1 Year

At approximately 10:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Emeshell Docejo, Designated Responsible Party (DRP). Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for one (1), and is approved for six (6) residents. At approximately 11:45 AM, LPA initiated a tour of the facility with DRP 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 within the allowable range of 105 to 120 degrees F per Title 22 regulations. 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 regulations. LPA observed two instances of cleaning chemicals accessible to residents in care. DRP secured the the items away from residents immediately and agreed to ensure that all cabinets containing cleaning supplies and other items that could pose a risk to residents in care would remain secured at all times. Facility has at least two days of perishable and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the front and backyards with outdoor space for visiting and activities. LPA observed a locked shed and a locked storage container in the backyard which contained care equipment, tools, and chemicals. LPA also observed a newly built fence securing the area of the property where two trailers are located and used for staff living quarters. Facility has internet service and an internet access device available for resident use as required per regulation. Continued on LIC809C... Continued from LIC809... Residents were observed engaging with staff and visitors, reading, and watching TV during inspection. LPA observed supplies for other activities. Facility's fire extinguisher was observed fully charged and the tag indicates it was last serviced 10/2024. DRP states the fire department inspected it within the last year and agrees to follow up on getting it re-tagged with the most recent inspection date. Smoke and Carbon Monoxide detectors were tested and operational during inspection. DRP states the facility conducts bi-weekly disaster drills, but facility log indicates the last drill was conducted 01/2026. LPA informed DRP that drills shall be conducted and logged no less than quarterly. DRP agrees to bring the facility into compliance immediately. LPA observed the facility's infection control plan, first aid kit, PPE, and emergency supplies for emergency preparedness. LPA reviewed facility's emergency disaster plan and DRP agrees to submit an updated plan to the Department. Facility has a back up generator for emergency preparedness. At approximately 2:00 PM, LPA reviewed five (5) resident records. Five (5) of five (5) residents' records contained the required documentation. DRP agrees to ensure that the correct LIC613 personal rights form is on file for each resident, specifically the LIC613C form for residential care facilities for the elderly. At approximately 3:00 PM, LPA reviewed four (4) staff records. Four (4) of four (4) staff records reviewed contained all the required paperwork including the required training hours and current CPR and first aid certificates. At approximately 4:00 PM, medications and medication records were reviewed and were observed managed and stored in compliance with regulation. DRP states that most of the residents' family members coordinate residents' medical and dental appointments and transportation to and from visits. However, facility assists with coordinating appointment and third party transportation when needed. Facility does not handle P&I. DRP provided LPA with proof of liability insurance. Continued on LIC809C... Continued from LIC809C... Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 Personnel Report (updated) LIC610E Emergency Disaster Plan (updated) No deficiencies cited during today's inspection. Exit interview conducted with DRP whose signature on for confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 29, 2026

Type of visit: Office

At approximately 12:00 PM, on 07/02/2025, an informal office meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio, Administrator, Alma Fuentes, and Licensee, Gemma D. Eugenio. The purpose of the informal office meeting was to discuss areas of non-compliance and observed concerns in the of the operation of Celebrity Haven II # 286800687. The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. The legal administrative action process was explained to attendees which is based on areas of non-compliance found during annual visit conducted on April 15, 2025. Items addressed in today's meeting include but are not limited to observed areas of noncompliance in the areas below: Fire Clearance Fire Inspector, Omar Galvan conducted a facility inspection on 05/22/2025 and denied the facility's fire clearance for the following reasons: All fire alarms and carbon monoxide detectors shall be interconnected Added wall in bedroom shall be either removed or permitted Updated evacuation map Hallway door shall meet egress requirements of the California Fire Code Continued on LIC809C... Continued from LIC809... On 06/27/2025 Inspector Galvan issued a conditional fire clearance under the condition that the facility be placed on Fire Watch and with the following items needing to be resolved within 30-days to comply with the Fire Marshal. Licensee agrees to maintain communication with the Napa City Fire Department to resolve the areas of non-compliance. Technical Support Provider (TSP) assistance was offered to Licensees during this meeting and agreed to engage services. No deficiencies were cited during today's office meeting. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 2, 2025

Type of visit: Office

On 4/30/2025, at approximately 10:00 AM, an informal meeting was conducted in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio and Alma Fuentes, Administrator. The purpose of the informal office meeting was to discuss areas of non-compliance and observed concerns in the of the operation of Celebrity Haven II # 286800687. The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. The legal administrative action process was explained to attendees which is based on areas of non-compliance found during annual visit conducted on April 15, 2025. Items addressed in today's meeting include but are not limited to observed areas of noncompliance in the areas below: - Fire Clearance - Restricted Health Condition - Medication Management -- Administrator to ensure all residents who consume alcohol have a physician's order or an LIC602 which indicates approval in their file and ensure all medications and supplements remain inaccessible to residents in care at all times - Resident Records -- must be complete with required documentation - Personnel Records – must be complete with required documentation Continued on LIC809C... Continued from LIC809... - First Aid Requirements – Administrator to ensure that all staff have proof of current First Aid given by an American Red Cross provider - Buildings and grounds Administrator provided the Department the following documents during today's office meeting: - Proof of current first aid certification for each staff member - Updated facility sketch to initiate fire inspection of the converted bedroom and two trailers on the property LPA Advised the following documents shall be submitted to the Department within 30 days of this meeting: - Self-certification that all staff records are complete per regulation - Self-certification that all resident records are complete per regulation Licensing staff discussed Technical Support Program (TSP) that offers advice, guidance, a review of facility operation, discusses best practice, and required regulation/HSC compliance. Licensee agreed to reach out to the Department if they would like to utilize the TSP assistance benefit in the future. Failure to submit any of the above requested documentation may result in the Department seeking further action. No deficiencies were cited during today's office meeting. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Apr 30, 2025

Type of visit: Required - 1 Year

At approximately 10:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by facility Staff. Alma Fuentes, Administrator, was contacted via telephone and arrived within approximately five minutes. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for one (1), and is approved for six (6) residents. Facility does not currently have any Hospice residents in care. At approximately 10:45 AM, LPA initiated a tour of the facility with Administrator 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 slightly above the allowable range of 105 to 120 degrees F per Title 22 regulations. Administrator agrees to monitor the temperatures to operate within 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 observed locked. However, LPA observed supplements in the medicine cabinet of an unlocked staff bathroom and an open bottle of wine in the facility refrigerator. Administrator had staff secure both immediately. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA inspected three locked sheds in the backyard which contained care equipment, tools, and chemicals. LPA also observed two trailers on the premises which are currently being used for staff living quarters. Continued on LIC809-C... Continued from LIC809C... LPA observed residents in the common area and in their bedrooms. Administrator states staff engage residents in daily chair exercises, facilitate games time, coordinate musicians performing in the facility and more. Facility telephone was tested an operational during inspection. Facility's fire extinguisher was observed charged and was last serviced 10/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 1/2025. LPA observed the facility's infection control plan and a supply of PPE. Facility has a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan last updated 02/2025. LPA observed structural changes within the facility to resident bedroom number one (1) which now has an internal wall and door installed; resident living in a room cleared for staff, and two trailers currently being used for staff living quarters that are not accurately reflected on the facility sketch and are not on the current fire clearance as required per regulation. LPA informed Administrator that any required permits for the structural changes will need to be obtained, if applicable, prior to Administrator submitting a new facility sketch to Licensing requesting a new fire clearance. Administrator agrees to keep LPA informed on their progress. LPA reviewed five (5) resident files and five (5) staff files. Five (5) of five (5) staff files were observed missing proof of CPR and/or First Aid training from an approved American Red Cross provider as required per regulation. LPA observed no personnel records maintained at the facility for the Licensee who the Administrator states works at the facility occasionally and who performs staff in-service training sessions in her role as a registered nurse. Additionally, Staff 4 (S4) was missing proof of a health screening. Five (5) of five (5) resident files were reviewed and the file for Resident 5 (R5) observed with a wound on their right foot, contained a pre-appraisal from 2017 when the resident was admitted which states that the wound was a "stage II" wound. No orders, exceptions, care notes, or other required documents were observed. Further, based on file review, LPA discovered that Resident 2 (R2) has a suprapubic catheter. LPA did not observe an exception or any care notes related to this. LPA will return to the Department and conduct further file review and gather more information regarding the above residents. Continued on LIC809C... Continued from LIC809C... LPA observed four (4) of four (4) resident records missing a consent for emergency medical treatment at required per regulation as well as three (3) of five (5) residents files were observed missing physician's orders for a hospital bed with half rails as said beds were observed in use by all residents in the facility during today's inspection. LPA reviewed medications and medication logs which were observed stored and maintained within regulation. Facility does not manage P&I. Administrator stated they would like to apply for a change of ownership sometime this year under a new entity name and LLC. LPA will consult with Licensing Program Manager and determine whether an in office meeting is indicated. LPA will issues citation at a later date either in-office or will return to the facility to do so. No deficiencies were cited during today's inspection. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Apr 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 10:00AM to conduct an Annual Required inspection and was greeted by Administrator. LPA and Administrator discussed the purpose of the visit. LPA initiated a tour of the facility around 10:15AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathroom used by residents measured at 134 degrees F which is not within the range of 105 to 120 degrees F allowed per regulation. Administrator immediately turned down the hot water heater. Administrator agrees to keep a hot water temperature log until water temperature gets into the required range per regulation. LPA observed the drawer containing knives did not have a lock on it. However, staff are constantly supervising residents. LPA and Administrator discussed keeping a magnetic lock on the drawer to ensure extra security. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food and water supplies are stored in the pantry as well as the shed outside and are rotated. Fire extinguishers were last serviced October 12, 2023. Smoke detectors located throughout the facility were tested and operational during inspection. LPA and Administrator were unable to locate the carbon monoxide detector. Administrator agreed to purchase a new carbon monoxide alarm and have it installed this week. Most recent fire/disaster drill was conducted 01/04/2024. Continued on LIC809C Continued from LIC809 Four staff files and three resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administrator Certificate for Administrator, Alma Fuentes (6013408740), is up to date and expires 02/11/2025. Medications and medication records were reviewed. No deficiencies cited during inspection. Administrator to submit updates of the following documents by 03/29/2024: LIC 500 Personnel Summary Copy of Liability Insurance LIC 9020 Register of Residents Emergency Disaster Plan (If changes) Infection Control Plan (If changes) Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 29, 2024