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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 01/26/2021
Date Signed: 02/24/2021 12:55:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:BROOKDALE NAPAFACILITY NUMBER:
286800493
ADMINISTRATOR:STEVEN MATTINGLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 75DATE:
01/26/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Steven MattinglyTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Angela Elliott and LPA Farhaan Sarangi met with Steven Mattingly, Executive Director via tele-visit to review two separate unwanted interactions between staff and a resident that were self-reported. It is being conducted via tele-visit due to COVID - 19 precautions.

The first incident was regarding a physical/verbal altercation between a S1 and R1 with no injury on 1/14/2021. S1 was observed speaking to R1 inappropriately and grabbing R1. According to Executive Director, S1 had received all the required training. S1 was terminated due to this incident, and Executive Director indicated there have been no adverse effects with R1 from the incident.

The second incident occurred when a S2 put R2's pendant out of reach on 1/14/2021. According to Executive Director, S2 had received all the required training. S2 has not been in the community since 1/15/2021 and is on suspension as the investigation continues. According to the Executive Director, there have been no adverse effects with R2 from the incident.

No citations issued at this time.

Signature on File.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2021
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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