<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 03/01/2021
Date Signed: 03/22/2021 10:16:40 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:STEVEN MATTINGLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 70DATE:
03/01/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ed Silva/Angela DomingoTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Angela Elliott held a tele visit with Ed Silva, Director of Operations and Angela Domingo, Manager of Carebridge Memory Care Unit to review incidents. Tele-visit was held due to COVID-19 precautions.

LPA received SOC341 on 2/25/2021 for incident occurring between R1 and R2 on 2/24/2021. R1 walked into R2’s room and wouldn’t leave. R2 threw water on R1 and R1 bit R2’s right finger. Staff broke up altercation, separated residents and provided support. There were no injuries and both residents are doing well. According to Ed R1 used to live in R2’s apartment and R1 went in and got confused. Staff are now in the hallway outside R2’s apartment to assist R1 with any potential confusion. LPA requested documentation.

When LPA asked about R3 it was reported R3 had an un-witnessed fall on 2/19/2021. R3 was sent Kaiser Vallejo ER and diagnosed with a left hip fracture, had surgery and returned to facility on 2/23/2020. Physical Therapy, Private Caregiver and frequent checks every 2 hours are in place. LPA requested documentation. Incident Report is pending.

No citations issued at this time.
Signature on file.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1