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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 11/02/2021
Date Signed: 11/02/2021 12:34:21 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
06/23/2021 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210623113620
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: 70DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
11:49 AM
MET WITH:Kim Humphrey (Administrator)TIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff did not properly reassess resident.
Staff did not notify responsible party of resident's change in condition.
Resident's grooming needs are not being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with with Executive Director (Administrator), Kim Humphrey and Wellness Director, Carlos Villela to deliver findings regarding the complaint allegations above.
Regarding allegation of staff did not properly reassess resident. Per responsible party, they had to pushed facility staff to have an assessment done for resident (R1), but R1 never received an assessment which was the reason why R1 was brought up to R1’s physician for an assessment. Based on observations, interviews and records review, R1 was assessed for a possible change of condition on 11/24/2019, 4/20/2020, 10/20/2020, 03/15/2021 and 4/23/201. R1’s assessments concluded that R1 will be assisted with medication management only and no changes of condition. Although the complainant alleges that R1 has dementia, LPA was unable to obtain documentation to confirm this change of condition. LPA obtained LIC602 medical assessment dated 8/2020 indicates that R1 does not have a diagnose of Dementia. A finding that the complaint allegation staff did not properly reassess resident is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Continues on LIC9099C…
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20210623113620
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: 11/02/2021
NARRATIVE
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Continued from LIC9099…

Regarding allegation of staff did not notify responsible party of resident’s change of condition. Based on interviews conducted with staff and records provided by the facility. LPA obtained facility care notes indicating different contacts made with R1’s responsible party due to possible change of condition. Per facility notes, Responsible party indicated that they were looking for another care facility in Sacramento and agreed to notify facility staff of their findings. On 4/15/21 R1’s responsible party notified facility staff that they have scheduled a neuro-consult for R1 next day between 9am to 2pm due to concerns of R1’s possible change of condition. Based on records review, facility staff had been in contact with responsible party regarding R1’s condition. A finding that the complaint allegation staff did not notify responsible party of resident’s change of condition is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation of resident’s grooming needs are not being met. During this investigation LPA made observation, conducted interviews and reviewed records. Reporting party provided information that R1 was observed disheveled and not well groom. Based on records review of R1 needs and services plan dated 4/20/20 R1 is independent with all ADL’s including grooming. Facility provided proof of assessments conducted on various dates and facility doesn’t provide assistance with dressing or grooming needs. On 9/9/21 and 10/12/21 LPA conducted a tour through the facility and observed residents in care appeared to be well groomed and dressed appropriately including R1. On 10/12/21 LPA attempted to make observations at R1’s apartment and access was declined by R1. LPA conducted confidential interviews with staff on 9/9/21 and 10/12/21 confirmed that staff do not assist R1’s with their grooming needs. Based on facility investigation did not reveal that per observations made and interviews conducted LPA was not able to obtain information to support that resident’s grooming needs are not being met. A finding that the complaint allegation resident’s grooming needs are not being met is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2