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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 04/22/2021
Date Signed: 09/20/2021 09:58:04 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 NAPAFACILITY NUMBER:
286800493
ADMINISTRATOR:ED SILVAFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 63DATE:
04/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ed SilvaTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Angela Elliott held a tele visit with Ed Silva, Director of Operations to review incidents. Tele-visit was held due to COVID-19 precautions. LPA requested documentation.

CCL received incident report on 4/09/2021 for incident occurring on 4/8/2021 when R1 yelled at R2 and pushed R2 off their scooter causing abrasions on left forearm. R2 received first aid. Napa Police as well as responsible party were contacted. Ed indicated R1 has an appointment with Physician tomorrow to discuss behavior and possible cognitive decline. According to Ed R1 had increased confusion. R1 has a companion 12 hours a day and staff are monitoring both residents to minimize any further unwanted contact.

CCL received an incident report for an incident occurring on 4/21/2021 for incident occurring on 4/19/2021. when R3 pushed R4 out of their room. R4 hit their head against the back wall and fell to the ground. 911 was called and R4 was evaluated at Kaiser Vallejo for a fall with a flattening of vertebrae to mid to lower spine. R3 and R4 have temporary Service plans put in place and staff are redirecting residents away from each other. R3 was in an altercation with R5 on 2/24/2021. R4 has had altercations with R5 on 3/4/2021, 3/8/2021, and 3/19/2021. Regional Memory Care Specialist has been called in for consultation.

LPA also conducted tour of kitchen and dining area at facility.

No citations for deficiencies issued.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
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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