286800493-12-10-2021-21-AS-CMAZ-C9ZTTE-20211224140038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 12/10/2021
Date Signed: 12/10/2021 01:44:30 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
10/26/2021 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20211026114813

FACILITY NAME:	BROOKDALE NAPA		FACILITY NUMBER:	286800493
ADMINISTRATOR:	HUMPHREY, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LN		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	108	CENSUS:	DATE:	12/10/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Kim Humphrey (Administrator)		TIME COMPLETED:	01:54 PM

ALLEGATION(S):

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-Staff left resident on the floor for an extended period of time.
-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.

Reporting party alleges that Staff left resident on the floor for an extended period of time. Based on records review of self-incident report dated 9/5/21 and submitted to CCL on 10/29/21 resident R1 had an unwitnessed fall at approximately 6:55am, R1’s responsible party arrived at the facility to notify staff that R1 had fallen, staff on duty checked R1 for injuries related to the fall and 911 was contacted to transport R1 to the emergency room for evaluation. Emergency medical services records (Incident# E210901785) obtained on 11/19/21 indicated that on 9/5/21 at 6:58:22 a call was received from facility. On 10/27/21 LPA conducted interviews with witness revealed that R1 had an unwitnessed fall on 9/5/21 around 5:30am, was yelling for assistance from staff, but no one arrived.

Continues on LIC9099C…

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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 5

Control Number 21-AS-20211026114813

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…

R1 contacted their responsible party to tell them about the fall and staff was unable to be located. Responsible party tried calling the facility five times without any success then drove to the facility, the front door was locked, tried calling again and could hear the phone ringing at the front desk when another resident came into the lobby and opened the door. Administrator confirmed this information and informed LPA that it was a phone issue because at night the staff are supposed to transfer over the calls to the med-technician’s room and it seems like that night they didn’t set the phones to be transferred over. Per Administrator, there is a new system of double checking every night the phones to make sure that staff is able to answer the calls. Based on records review of timesheets for the month of September 2021 provided by the facility that the night of the incident there were at least two staff on shift from 10:30pm to 6:30am. 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.

Regarding the allegation of personal rights, it was alleged by reporting party that staff did not protect R1’s personal items and did not prevent inappropriate interactions between residents in care. Based on records review, on 9/30/21 the facility submitted a SOC341 alleging physical abuse resulting on bruises on R1’s arm performed by resident R2. The facility agreed with R1’s responsible party to hire a one on one companion from 8am to 8pm to be with R2 until further notice. On 11/3/21 CCL received a self-incident report dated 8/30/21 reporting that on 8/6/21 R2 had an aggressive incident towards another resident were R2’s care plan was reassessed. However, during interviews conducted and acknowledgement of R2’s behavior towards residents in care R2’s personal services plan dated 12/1/2019 was not updated. On 11/30/21 interviews conducted with Administrator confirmed that R2 had a habit of going into other resident’s rooms, R2 will take their clothes, items and hit the walls with their hands. Per Administrator, R2 was sent to their Physician for evaluation, there were medication changes that resulted in R2’s behaviors were ceased. 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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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)

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Control Number 21-AS-20211026114813

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 HSC 1569.269(a)(6)	1 2 3 4 5 6 7	§1569.269 (a)(6) Enumerated rights (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision & services that meet their individual needs & are delivered by staff that are sufficient in numbers, qualifications & competency to meet their needs. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	Administrator agrees to submit a written plan to ensure facility is following up on residents’ needs, staff qualifications, numbers and training.
	8 9 10 11 12 13 14	Based on LPA observation, interviews and records review, the facility staff did not ensure that R1 was assisted in a timely manner by staff after a fall which poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14	Administrator requested additional time to submit POC by 12/15/21 due to short staff
Type A 12/11/2021 Section Cited CCR 87468(a)	1 2 3 4 5 6 7	87468 (a) Personal Rights (a) Residents in RCFE shall have personal rights… This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will ensure resident rights are not violated. Administrator agrees to submit plan of how resident needs will be addressed without violating the rights of other residents by xxx. **Civil Penalty assessed in the total amount of $250.00 for repeated violation during visit on 5/28/21.
	8 9 10 11 12 13 14	Based on LPA observation, interview and record review facility did not ensure that residents personal rights were violated which poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14	Administrator requested additional time to submit POC by 12/15/21 due to short staff

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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: 5 of 5

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
10/26/2021 and conducted by Evaluator Marisol Cuadra

COMPLAINT CONTROL NUMBER: 21-AS-20211026114813

FACILITY NAME:	BROOKDALE NAPA		FACILITY NUMBER:	286800493
ADMINISTRATOR:	HUMPHREY, KIMBERLY		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LN		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	108	CENSUS:	DATE:	12/10/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Kim Humphrey (Administrator)		TIME COMPLETED:	01:54 PM

ALLEGATION(S):

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Facility failed to ensure appropriate medical care was provided

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.

It was alleged by reporting party that staff gave the resident R1 a flu vaccine without consent. Based on interviews and records review, R1’s responsible party stated that they gave staff verbally permission to administer flu vaccine as long as it was a regular dose and not the “super mega/dose” given to seniors that makes the resident very sick. On 10/8/21 the facility hosted a flu vaccination clinic. After the shot, R1 was very sick for one week, wasn’t eating, could barely walk, was incoherent, broke out with red scabs on their nose when they inquired about which flu shot did R1 received the facility staff could not provide any information. LPA conducted interviews with Administrator and confirmed that facility does not have information about which flu vaccine was administered to residents in care. Based on records review obtained on 10/28/21 from CVS pharmacy, R1 received on 10/8/21 Fluad Quad 2021-2022 syringe which is an active immunization of persons 65 years of age and older against influenza disease.
Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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 5

Control Number 21-AS-20211026114813

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 LIC9099A...

During records review of R1’s file, LPA was not able to obtain any supporting documentation that confirmed that R1’s responsible party had signed a written consent indicating the preferred type of flu vaccine to administer to R1. A finding that the complaint allegation staff gave the resident R1 a flu vaccine without consent 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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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)

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