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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 12/10/2021
Date Signed: 12/10/2021 01:56:29 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
10/25/2021 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211025082804
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: 72DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kim Humphrey (Administrator)TIME COMPLETED:
02:11 PM
ALLEGATION(S):
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Staff do not administer residents' medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Executive Director (Administrator), Kim Humphrey to deliver findings regarding the complaint allegations above. LPA conducted risk assessment call with Executive Director, Kim Humphrey prior to the visit.
Regarding allegation of Staff do not administer residents' medication as prescribed. Reporting party alleged that facility staff (S1) did not crushed resident’s (R1) medication as prescribed. Based on records review and observations made at the facility on 11/2/21 and 11/29/21. Facility provided R1’s Physician order effective June 24, 2021 indicating that R1 had a decline in health that resulted in R1 was admitted to initiate hospice care a diet change to pureed and thickened liquids, medication may be crushed and mixed with liquid, and a visit frequency of twice a month for two months to receive hospice services. Care notes of home health nurses who helped provide hospice services for R1 did not observe evidence of neglect from care staff not administering medication as prescribed. Based on records review of facility care notes and confidential interviews conducted on 10/28/21, 11/30/21 and 12/6/21 revealed that S1 had been performing multiple medication errors involving at least three other residents in care on 8/14/21 and 10/6/21. After incidents, the facility provided S1 with re-training course and 16 hours of medication pass observation.
Continues on LIC9099C…
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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 4
Control Number 21-AS-20211025082804
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: 12/10/2021
NARRATIVE
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Continued from LIC9099…

Administrator confirmed this information and provided facility incident reports that were not submitted to CCL within timeframe stated per regulation. Interviews conducted with S1 confirmed that R1 doctor’s instructions order was not entered in the system, staff was verbally instructed by other medication technicians to assist R1 with one pill at a time. However, R1 was having a hard time swallowing the pills, S1 was not aware of the crushed order until S1 was provided with a binder for R1 including prescribed doctor’s crushed order. On 11/30/21 during visit conducted by LPA the Administrator informed that the facility is in the process of implementing a new communication log system for medication technicians to look for special instructions for each resident in care. Also, LPA obtained pharmacy audit and report dated 11/2/2021 indicating some reminders and discrepancies found regarding medications that are delivered to residents in care. However, LPA reviewed incident report logs for this facility, and it was determined that some incident reports were not submitted to CCL within seven days of occurrence per regulation. LPA will address reporting requirements on a case management inspection. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties

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

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
10/25/2021 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20211025082804

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: DATE:
12/10/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kim Humphrey (Administrator)TIME COMPLETED:
02:11 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Executive Director (Administrator), Kim Humphrey to deliver findings regarding the complaint allegations above. LPA conducted risk assessment call with Executive Director, Kim Humphrey prior to the visit.

Regarding allegation of personal rights. It was alleged by reporting party that staff (S1 and S2) verbally abuses residents in the memory care unit of the facility. Based on LPA’s observations, records review and confidential interviews conducted with staff five out of five and five out of five residents in care during facility visits conducted on 11/2/21 and 11/30/21 did not indicate any information that supports that resident’s personal rights are being violated by staff at the facility. A finding that the complaint allegation personal rights 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.
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: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20211025082804
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2021
Section Cited
CCR
87411(a)
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Type A 87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers & competent to provide the services necessary to meet resident needs…This requirement has not been met as evidence by:
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Per Administrator, the facility is in the process of implementing a communication log system for med-techs. Administrator agrees to submit a written plan in how the facility will ensure that resident’s medication orders will be followed to prevent medication errors to CCL by POC due date of 12/11/21. **Civil Penalty assessed in the total amount of $250.00 for repeated violation during visit on 5/28/21.
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Based on records review and interviews conducted with Administrator and staff, facility staff did not provide staff with instructions about R1's medication crushed order which poses an immediate risk to the health and safety of residents in care.
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Administrator requested additional time to submit POC by 12/15/21 due to short staff
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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: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4