286800493-5-28-2021-21-AS-BMOS-C3LNVD-20210602104746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 05/28/2021
Date Signed: 05/28/2021 12:40:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2021 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210126151235

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: 86	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Kimberly Humphrey		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility does not have enough staff to meet resident needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via tele-visit, with Kimberly Humphrey, Executive Director for the purpose of delivering findings for above allegations. It is being conducted by tele-visit due to COVID - 19 precautions.

There is an allegation facility does not have enough staff to meet resident needs. Alarm Response Report from call response logs from 3/21/2021-5/17/2021 show over 600 response times logged between 10 and 30 minutes, over 100 response times logged between 30 and 60 minutes and over 50 response times logged exceeding 60 minutes. Operations Specialist provided staffing schedules from 11/29/2020-2/28/2020 which reflect intermittent days when staffing minimums were not met based on interview with Former Executive Director on 1/1/2021 and e-mail sent by Operations Specialist on 3/15/2021. COVID-19 has been at the facility. According to Operations Specialist ancillary staff also worked the floor, but documentation to support this could not be provided.
(See LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210126151235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/28/2021

NARRATIVE

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Multiple interviews with staff and residents revealed staffing shortages have been an issue since January of 2021. E-mail dated 5/6/2021 from Operations specialist indicates there are 5 two person assist residents at Brookdale and several residents have had altercations resulting in injury. On 4/19/2021, R3 pushed R4 out of their room. R4 hit their head against the back wall and fell to the ground. R4 sustained a fall with a flattening of vertebrae to mid to lower spine. According to Operations Specialist during case management on 4/22/2021, R3 had a temporary Service plan put in place that staff are redirecting residents away from each other. R3’s Personal Service Plan states redirect resident to their most familiar and comfortable area of the community if disruptive to others. R3’s Personal Service Plan dated 9/16/2020 does not reference behaviors. R3 was also in an altercation and bit R5’s finger on 2/24/2021. R4 has had altercations with R5 on 3/4/2021, 3/8/2021 sustaining skin tear, and 3/19/2021. Personal service plan for R4 reflects; “Staff to round frequently and redirect as needed after 3/4/2021 incident, staff to redirect to apartment or engage in activities that R4 enjoys. Staff to ensure other rooms are locked to prevent any altercations with other residents.” R5’s plan dated 12/28/2020 discusses altercation between R5 and R4 on 3/9/2020 and reflects “Staff to monitor resident involved and engage them in activities. R5’s Personal Service Plan dated 3/24/2021 reflects “Staff to closely monitor R5 and re-direct R5 away from former roommate to prevent further altercations”. Interview with outside party on 4/29/2021 indicated staffing problems started in October of last year but then became overwhelming in the beginning of this year and onward. Based on LPA observations, interview and record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights will be sent to the Administrator. Exit interview was conducted and a copy of this report was emailed to the Administrator for signature.

(See LIC 9099-D)

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210126151235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/28/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure sufficient staffing to meet the needs of residents. Licensee agrees to submit updated staffing schedule, showing 24-hour coverage to meet the needs of residents. Updated staffing schedule to be submitted to CCL by COB 6/1/2021.
	8 9 10 11 12 13 14	Based on LPA observation, interview and record review facility has five two-person assists, delayed call response times and has had several client to client altercations resulting in injury. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.	8 9 10 11 12 13 14
Request Denied Type A 05/28/2021 Section Cited CCR 87465(a)	1 2 3 4 5 6 7	87468 Personal Rights (a) Residents in residential care facilities for the elderly shall have personal rights. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will ensure resident rights are not violated. Executive Director agrees to submit plan of how resident needs will be addressed without violating the rights of other residents by 6/1/2021
	8 9 10 11 12 13 14	Based on LPA observation, interview and record review facility implemented plan to lock resident bedrooms to prevent altercations with residents. This is an immediate risk to the health safety and personal rights of residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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