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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 09/30/2021
Date Signed: 10/06/2021 11:07:30 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:HUMPHREY, KIMBERLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 67DATE:
09/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:59 AM
MET WITH:Kimberly Humphrey, AdministratorTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrator, Kimberly Humphrey. The purpose of this case management inspection was to follow up on self reported incident report submitted to Community Care Licensing (CCL) on 9/21/21.

On 9/17/21, R1 was found by S1 attempting to commit suicide. S1 radioed for help. S2 arrived and called 911. Paramedics showed shortly. Resident was under medical supervision. Facility provided CCL with documentation for R1 including Physician Report and Personal Service Assessment on 9/23/21. During inspection, LPA Lopez requested additional documents including R1's Care Plan. LPA took statements from Administrator. Facility contacted responsible party, 911, and Physician. Resident has returned to facility and is receiving one on one companion for R1's safety. The incident reported 9/21/21 for R1 stated that facility had removed items that could potentially harm resident. During inspection LPA observed R1's room and noticed there were a few items that could potentially harm resident. Items found were a bottle of Windex, a 28 FL Oz bottle of sanitizer, detergent, and disinfecting wipes. Administrator took items out of R1's room immediately.

During Case Management- Incident inspection, Administrator stated to LPA that an SOC341 was being reported due to R2 being aggressive with R3. LPA asked for documentation and took statements from Administrator and S4. S4 and Administrator stated that R2 has had multiple similar incidents previously and have been in contact with Physician. SOC341 was reported to CCL, Police and Ombudsman today 9/30/21. Administrator also spoke with R2's responsible party 9/30/21. Facility will follow up with responsible party about further plans with R2.

Appeal Rights Provided.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Kimberly Humphrey, Administrator, whose signature below confirms receipt of report.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/06/2021
Section Cited

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87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

**This requirement was not met as evidence by:
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Based on observation LPA found that toxins were accessible to resident that was recently discharged from attempted suicide. Facility stated in incident report that was reported to Community Care Licensing on 9/21/21 that all items that could be harmful to resident were removed.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021
LIC809 (FAS) - (06/04)
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