Nazareth Rose Garden of Napa

Allegation investigated: Staff do not answer residents calls for assistance timely

On 06/25/2026, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to obtain additional information, conclude complaint investigation, and deliver complaint #21-AS-20260402105752 investigation findings regarding the above allegation and met with Minerva Villegas, Designated Responsible Party. On 04/02/2026, LPA initiated this complaint investigation and obtained documents, made observations, and conducted an interview. Based on staff schedules obtained for 03/2026 and 04/2026 and staff observed on site during the visit, the facility meets and/or exceeds the minimum required staffing of at least one awake staff member in each unit on all shifts. Today, 06/25/2026, LPA returned to facility to conduct interviews, obtain additional documents, and make observations. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... An interview with the Designated Responsible Party revealed that the facility has a centralized call system which can be activated by residents in their rooms and alerts care staff via a switchboard in the medication room that lights up to indicate which room and bed is calling for assistance and generates an audible sounds as well. However, the facility's call system does not track call response times. Further, LPA observed four staff in the common area assisting residents and two additional care staff rounding with peri care kits to assist residents with their activities of daily living upon arrival to the facility. Additionally, LPA was unable to obtain evidence that any adverse events have occurred as the result of the current staff to resident ratios. Based on interviews conducted, observations made, and documents obtained, LPA received conflicting information. Based on interviews conducted, observations made, and records obtained, the allegation that staff do not answer residents calls for assistance timely is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Designated Responsible Party, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Jun 25, 2026 · control 21-AS-20260402105752

Allegation investigated: Staff did not address a resident’s scabies infection in a timely manner.

On 12/02/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250903164551 investigation findings regarding the above allegation and met with Shanti Ragland, Administrator. Reporting Party (RP) alleges that staff did not address a resident’s scabies infection in a timely manner. LPA Florio conducted 10-day complaint investigation visit on 09/04/2025 and obtained documents and made observations. Per physician's reports dated 09/22/2022 and 11/19/2024, no skin conditions were mentioned for Resident 1 (R1). On 10/28/2025, LPA returned to facility to conduct interviews, obtain additional documents, and make observations. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Per documents obtained during this visit, Hospice orders for R1 revealed medications specifically prescribed for scabies dating back to 12/2023. Additionally, obtained Hospice progress notes dated from 06/17/2024 through 07/17/2025 do not mention scabies specifically -- only observed rashes and itching and recommendations for addressing the symptoms, such as continuing with washing affected areas and applying ointments and giving medications as prescribed. Centrally stored medication destruction records and medication administration records for R1 during the months of July and August 2025, revealed that the medications were given as ordered when the facility was able to get them refilled. Per an interview with Staff 1 (S1), R1 graduated off Hospice around July 15, 2025 which was providing R1 with two (2) additional baths per week and physician oversight to order and refill prescriptions. Per S1, facility staff observed R1's rash worsening around the beginning of August and notified the family and R1's prior primary care physician (PCP). The PCP notified the facility they were retiring and that R1 would need to find a new PCP. However, PCP referred R1 for home health services in the interim. Per S1, the facility's recommended physician would not accept R1, so the family found their own PCP, who per a Healthcare Provider Communication form dated and signed 08/09/2025, evaluated R1 and indicated suspected scabies which were later confirmed by a dermatologist on 08/14/2025. Per interview conducted with S1 and medication administration records for 08/2025, the facility immediately followed the doctors orders in regards to cleaning, bathing, care, treatment, and isolation. S1 states that the rash has cleared and R1 is doing better. Today, 12/02/2025, LPA interviewed complainant who indicated that R1's skin has improved and has cleared up. LPA was unable to find any evidence to support that the facility staff did not address a resident’s scabies infection in a timely manner. Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding the above allegations. Based on interviews conducted, observations made, and records obtained, the allegations that staff did not address a resident’s scabies infection in a timely manner is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 21-AS-20250903164551

Type of visit: Required - 1 Year

At approximately 10:00 AM, Licensing Program Analysts (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Shanti Ragland, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with thirty (30) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for eleven (11), with five (5) Hospice residents currently in care, and is approved for forty-four (44) non-ambulatory residents and ten (10) bedridden resident. At approximately 10:30 AM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one story building, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured between 95.3 degrees F and 139.6 degrees F. LPA informed Administrator that the allowable range is 105 to 120 degrees F per Title 22 regulations. Facility has four (4) separate water heaters and water temperatures vary greatly between faucets closer to each water heater and those further away. Administrator had staff turn up two water heaters where water temperatures tested below the allowable range, and Administrator agreed to post hot water warning signs at every faucet in the facility that tests above the allowable range in order to bring the facility 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 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. 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 courtyard with outdoor space for activities. LPA observed residents engaged in morning exercises and later engaged in crafting activities. Facility has a monthly activity calendar posted with several activities planned each day. Continued on LIC809-C... Continued from LIC809... LPA observed a supply of puzzles, games, and crafting supplies available for residents in care. Facility has internet access and Administrator agrees to ensure an internet access device is designated for resident use. Facility telephone was tested an operational during inspection. Facility has several fire extinguishers which were observed charged and were last serviced 07/2025. Facility passed their last fire system inspection and testing conducted by a third party vendor 09/2025. Facility conducts quarterly disaster drills with the last one completed on 10/2025. LPA observed the facility's infection control plan, first aid kit, PPE, flashlights, and emergency supplies. LPA observed a solar panel system and generator for emergency preparedness. LPA reviewed facility's emergency disaster plan which was last updated 05/2024. At approximately 12:30 PM, LPA conducted file review. LPA reviewed five (5) staff and five (5) resident files and observed the following: five (5) of five (5) staff files reviewed contained the required paperwork including proof of current FA/CPR per regulation. Five (5) of five (5) staff files reviewed were short two (2) hours of Hospice, postural supports, and/or restricted health conditions training. Administrator has scheduled an all staff training for this Friday to ensure facility is brought back into compliance immediately. Five (5) of five (5) resident files reviewed contained the required paperwork per regulation. At approximately 3:00 PM, LPA reviewed medications and medication records which are maintained and stored in compliance with regulation. Administrator states that the residents families coordinate residents' medical and dental appointments and transportation to and from visits. However, facility will assist with coordinating these appointments and transportation for residents upon request. Facility does not manage P&I. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: -LIC610E - Emergency Disaster Plan (updated) -LIC500 Personnel Report (updated) 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, Nov 17, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Julie Florio conducted a case management- incident inspection on 05/13/25 at approximately 3:00 PM, and met with Mark Sanga, Wellness Coordinator. LPA is conducting a case management visit to obtain more information and conduct a safety and wellness check regarding two incident reports and a SOC341, dated and received by the Department on 05/12/2025, involving Resident 1 (R1) which were self reported by the facility Executive Director. LPA interviewed R1, reviewed R1's records, and obtained copies of documents including a personnel roster/report. No deficiencies were cited during todays visit. Exit interview was conducted with Wellness Coordinator, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Case Management - Incident

At approximately 1:30 PM, on 4/24/2025, Licensing Program Analyst (LPA) Julie Florio conducted a case management- incident follow up visit and met with Shanti Ragland, Administrator. This visit is being conducted to obtain more information regarding an incident report which was received by the Department on 04/17/2025 and a corresponding SOC341 received by the Department on 04/18/2025. The incident was allegedly regarding finances between staff 1 (S1) and resident 1 (R1). LPA made observations, obtained documents, and conducted interviews (see LIC812s). LPA will follow up with the local police as well. No deficiencies were cited during todays visit. Exit interview was conducted with Administrator, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Apr 24, 2025

Type of visit: Case Management - Annual Continuation

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 visitthe state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Case Management - Incident

At approximately 9:15AM, Licensing Program Analyst's Star Stevenson and Chris Arnhold arrived at this facility unannounced to conduct a an annual required continuation inspection. LPA's conducted this case management visit in regards to an allegation of abuse. LPA's met with Administrator Shanti Subba, interviewed staff and reviewed records. Based on interviews conducted, Resident, R1, is a newer resident to the facility. They have a tendency to wander and ended up wandering into Resident's, R2, room. Staff were alerted by R2 that someone was in their room. Staff responded and escorted R1 out of the room. LPA received copies of documents. The Department will follow up for further details. No citations issued during this visit.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Required - 1 Year

At approximately 12:00PM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Shanti Ragland and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit was present. Fire extinguishers were fully charged. Smoke detectors are all operational. Facility has fire sprinklers throughout. Carbon Monoxide Detector was present. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Hot water measure above regulation at facets accessible to residents. Facility has tried to conduct emergency drills quarterly, but has not documented them. LPA will return at a later date to review staff and resident records. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Shanti Ragland and Appeal rights were given.the state’s words, verbatim · CDSS document, Jan 21, 2025

Allegation investigated: Staff has not addressed scabies outbreak in facility

At approximately 08:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegation. LPA met with Administrator Shanti Subba, reviewed records and toured the facility. LPA received copies of documents. Based on records reviewed and interviews conducted, resident (R1) was admitted to the facility 07/17/2024, and was given a head to toe examination. This exam revealed some redness on the front of the body. Resident did not display any discomfort until September 30th. Facility notified the physician and requested treatment. Facility continued to document and monitor and was in communication with the physician. An appointment was scheduled with a physician for another examination but due to resident behaviors, the appointment did not help. Facility continued to communicate with physician to address the skin condition. Home Health was ordered to evaluate resident, but do to insurance issues, the home health visit did not occur. Facility continued to communicate with the physician on a course of treatment. Based on records reviewed, there have been no tests done to diagnose the skin condition to confirm scabies. There are no diagnosed cases of scabies in the building. This agency has investigated the above allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Unfoundedthe state’s words, verbatim · CDSS document, Jan 9, 2025 · control 21-AS-20241025143410

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct an annual required - 1 yr. visit of the facility. LPA was welcomed by staff Josefina Harris who contacted Administrator, Minerva Villegas for today’s visit. Current Administrator Villegas and soon to be Administrator Shanti Subba Pickett arrived during the inspection. There is a total of 19 residents, 14 with a diagnostic of dementia. There is 8 residents currently on Hospice. LPA toured the facility on 12/27/2023 at 8:50 AM with staff; facility was found to be clean and in good repair at a comfortable temperature with all exits free from obstruction. Exit alarms were working properly. Facility serves residents with dementia and has a plan of operation for special care and programming. All bedrooms inspected have lighting & appropriate furnishings. LPA observed residents were participating in an exercise activity. There was a sufficient supply of both perishable and nonperishable food as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins were locked and secured. Facility has extra fresh linens and hygiene supplies available for residents. Hot water temperature measured 110.1, 118.7, 122.3, 123, 129.7, 137.8 & 140.5 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 3 of 5 resident’s bathrooms & the 2 shower rooms while touring facility on 12/27/2023, (see LIC809-D). Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. Facility has smoke detectors and sprinkler system. Fire panel was last inspected 10/26/2023. Fire Extinguisher was found to be last charged on 7/26/2023 at the time of the visit. Carbon monoxide detectors were found to be operational during the visit. A review of 5 residents & 5 staff records as well as resident’s medications was conducted during this visit. LPA reviewed resident’s files at 11:15 AM on 12/27/2023 and learned that 5 of 5 residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A) on file. Continue LIC 809-C At approximately 1:15 PM LPA reviewed a sample of staff records and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff files have proof of annual training requirements on file. LPA was presented with proof of CPR; although 2 of 4 care staff (S1 & S2) files reviewed did not have current 1st Aid certification (see LI809-D). Medications inspected were in their original containers. Facility has a written medication administration record (MAR) and provided a copy of their last medication audit conducted by an outside agency dated 10/20/2023 stating the facility was found in compliance with medication storage, first aid kit, medication centrally stored, destruction records including medication refrigerator storage and controlled narcotics. LPA reviewed Licensing Information System (LIS) with administrator who stated that is corrected and updated at this time, although there is a new Administrator change. In addition, LPA advised facility to check with the County regarding what is the County Emergency Plan; ensure that disaster drills are conducted in different shifts, and review facility emergency plan to ensure accuracy according to the needs of facility residents. Disaster Drills have only been conducted once to twice a year, with the latest 3/2023 (see LIC 809-D). Minerva Villegas Administrator Certificate # 6065970740 expires on 10/21/2025. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and 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 and appeal of rights provided. LPA Hansen is requesting facility to submit the following documents to CCL by 1/15/2024: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Copy of Current Administrators Certificate Copy of Control of Property/New updated Lease Copy of Certificate of Liability Insurancethe state’s words, verbatim · CDSS document, Dec 27, 2023