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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 03:17:24 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Kimberly Humphrey, AdmnistratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Lopez conducted an unannounced case management inspection and met with Administrator, Kimberly Humphrey. The purpose of the case management inspection was to obtain additional information regarding self reported incidents submitted to Community Care Licensing (CCL).

LPA Lopez followed up on SOC341 from 5/19/20 regarding R1 being physically abused by S1. LPA conducted an interview with Administrator and gathered documentation. LPA Lopez is requesting additional documentation from Administrator that will be sent via email by 11/16/21.

On 10/25/21 there was an incident regarding R2 passing away. LPA Lopez followed up about incident and conducted interviews. Facility will reach out to LPA Lopez when facility obtains death certificate.

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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