286800493-2-26-2021-21-AS-AELT-BYLNXR-20210226095135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 02/22/2021
Date Signed: 02/26/2021 09:52:11 AM

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 NAPA		FACILITY NUMBER:	286800493
ADMINISTRATOR:	STEVEN MATTINGLY		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LN		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	108	CENSUS: 70	DATE:	02/22/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ed Silva, Regilyn Balliao, Lorie Bittles, Kadijatu Barrie		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Angela Elliott conducted a tele-visit with Ed Silva, Operations Director, Regilyn Balliao, Regional Resident Services Director, Lorie Bittles, Health and Wellness Director and Kadijatu Barrie, District Director of Clinical Services. It is being conducted via tele visit due to COVID -19 precautions. The purpose of this case management inspection is to follow up on five (5) self-reported incident reports submitted to Community Care Licensing (CCL). CCL received an incident report on 12/1/2020 for an incident on 11/17/2020 when Resident 2 R2 was discovered on the floor. 911 was called, R2 was admitted to Kaiser Vallejo for a hip fracture and passed away on 11/17/2020. LPA requested copy of the death certificate. A second incident report was submitted to CCL on 12/28/2020 for an incident on 12/20/2020 when Resident 3 (R3) had a change in condition. 911 was called, R3 was admitted to Queen of the Valley. R3 passed on 12/22/2020. LPA requested a copy of the death certificate. A third incident report was submitted to CCL on 1/04/2021 for an incident on 12/28/2020 when Resident 1 (R1’s) wife had called 911 due R1’s Primary Care Physician advising R1 be sent to the Queen of the Vallley Emergency Room due to rapid heartbeat. Medication order was updated and R1 returned to the facility the same day. Care plan was updated. R1 has frequent dialysis and was often dehydrated. It was determined R1 needed a higher level of care and has been transferred to a SNF. A fourth incident report was received by CCL on 1/4/2021 for an incident on 12/27/2020 when Resident 4 (R4) had a change in condition. 911 was called and R1 went to Queen of the Valley ER for evaluation and returned the following day without discharge instructions. LPA requested discharge instructions.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 NAPA	FACILITY NUMBER: 286800493
	VISIT DATE: 02/22/2021

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A fifth incident report was received by CCL on 2/17/2021 for incident that occurred on 2/17/2021. Resident 5 (R5) was given a double dose of evening medications due to S1 not documenting it had already been given on electronic medication record. R5 did not experience any adverse effects. R5 has been retrained on medication procedures and has not been passing medications since the incident.

No deficiencies cited at this time. Original signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

LIC809 (FAS) - (06/04)

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