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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 04/29/2021
Date Signed: 09/20/2021 09:56:44 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: 64DATE:
04/29/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ed SilvaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Angela Elliott held a tele visit with Ed Silva, Director of Operations and Regilyn Balliao, Regional Resident Services Director to review incidents. Tele-visit was held due to COVID-19 precautions. LPA requested documentation.

LPA requested information regarding how many two person assist residents are at the facility. Ed indicated four residents are two person assist; R1, R2, R3, and R4. LPA requested information on how many residents that are not on Hospice have wounds. Ed indicated there were none. LPA requested LIC 602, Care plan and Admission Agreement for residents requiring two person assist. LPA requested information regarding laundry service. Ed explained towels and linens are usually done once a week or as needed for incontinence needs. Personal laundry is done once a week and as needed for incontinence; PM shift gathers laundry, NOC shift washes laundry and AM shift puts laundry away. LPA also reviewed incident reports.

CCL received an incident report on 4/23/2021 for incident occurring on 4/18/2021. R1 had an un-witnessed fall, complained of back pain and 911 was called. R1 was evaluated at Queen of the Valley Emergency Room (ER) and was diagnosed with a compression fracture of the L1 vertebrae. According to Ed, R1 has resumed their normal activities and they are walking okay. LPA requested discharge instructions from the hospital and care plan.

CCL received an incident report on 4/23/2021 for incident occurring on 4/20/2021 where R2 appeared to be confused and Home Health Nurse requested R2 be sent out. 911 was called R2 was sent ot the ER and admitted to the hospital. R2 was diagnosed with a UTI (Urinary Tract Infection) , prescribed antibiotics and returned to the facility on 4/23/2021. According to Ed R2 has a catheter managed by home health and has UTI's. Ed also indicated R2 is still confused but urine is clear. LPA requested copies of R2's updated care plan. Regional Resident Services Director indicated their care plan needs to be updated and once updated it will be sent to LPA.

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

DATE: 04/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021
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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