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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 08/30/2021
Date Signed: 08/30/2021 04:07:40 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:HUMPHREY, KIMBERLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 68DATE:
08/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kimberly HumphreyTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Angela Elliott arrived unnanounced and met with Kimberly Humphrey, Executive Director and Juan Villela, Health and Wellness Director regarding incident reported on 8/13/2021.

R1 and R2 are roomates. R2 reported to a family member that R1 hit them on their arm and lef on 8/6/2021. The family member reported this to staff. Full Assessment was done on R2 with no injury noted. Staff interview of family member did not produce concrete details of alleged incident. Family member requested R2 be moved to another apartment. R2 moved to another apartment over the weekend following the incident. R1 has had a history of altercations, but no history with R2. Facility notified R1's doctor on 8/6/2021 regarding increase in behaviors for R1. Doctor added a new medication to R1's medication regimen. Facility has also reached out to R1's family to discuss appropriateness of placement and is awaiting a response. There have been no further altercations between R1 and R2.

LPA also inquired about incident report for alleged incident between R1 and R2. Executive Director indicated they would complete report and send it to LPA by COB 8/30/2021. LPA and Executive Director discussed importance of submitting incident reports within regulatory time frames.

No citations for deficiencies issued. LPA unable to print document will e-mail to Executive Director.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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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