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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:16:40 PM

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: 70DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Kimberly Humphrey, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Lopez arrived unannounced to conduct an Required- 1 year annual inspection and met with Administrator, Kimberly Humphrey. The annual inspection was focused on the Infection Control procedures and practices. LPA conducted risk assessment with staff.

LPA conducted a walk-through of the facility with Administrator and Juan Villela, Health and Wellness Director. Fire Extinguishers were found to be last charged on August 6, 2021. There was sufficient amount of supply for both perishable and nonperishable foods. LPA obtained a copy of facility fire inspection for 10/11/21.

LPA observed COVID-19 precaution postings but asked facility to add more postings. Front desk staff took LPA temperature, asked screening questions and documented on sign-in sheet. Visitors and staff are screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Resident's temperatures are taken once a day and documented. Staff clean and disinfect the facility at least once or more daily. Staff have completed training on infection prevention, symptoms, transmission and PPE use. The facility has a supply of PPE including gloves, face shields/goggles, N-95 respirators, surgical masks and disposable gowns. The facility has submitted a COVID-19 Mitigation Plan Report on Epidemic Outbreaks specific to COVID-19 which was approved by the California Department of Social Services.

LPA received the following documents:
Administrator Certificate, LIC500, LIC610E, LIC308 and Facility Liability Insurance.

Exit interview conducted with Administrator, whose signature on this document confirms receipt.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Karen LopezTELEPHONE: (707) 588-5048
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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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