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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 02/07/2022
Date Signed: 02/07/2022 01:51:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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: 71DATE:
02/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Kim Humphrey (Administrator)TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management visit with Kim Humphrey (Administrator).

- Community Care Licensing (CCL) received an incident report on 2/1/2022 for an incident occurring on 1/25/2022 for resident (R1). Around 10:00am resident aide reported to their Resident Care Coordinator (RCC) that R1 was not in their apartment and their breakfast meal was there untouched. Past lunchtime R1 had not returned. R1 did not sign out on the resident's binder, their car was not in the carport. RCC notified Administrator around 4:30pm-5:00pm about R1' was missing. Around 7pm R1 still was not back and responsible party was notified. R1 came back to the community around 10:40pm, the facility conduct an assessment and R1 did not have any injuries. During today's visit, LPA reviewed their Physician's Report (LIC602) dated 11/26/2021 that indicated that R1 was able to go out the facility unassisted.

- LPA also received an incident report on 12/15/21 for another incident involving resident (R2) occurred on 12/1021 around 3am when medication technician (S1) gave R2 an additional dose of Clonazepam 0.5mg as the resident was having episodes of anxiety with aggression. S1 notified Administrator and was instructed to look to see if R2 had any PRN medication available that would help with behaviors. S1 gave an anxiety medication that was not PRN in an attempt to help with resident's behaviors. The facility requested a psychiatry appointment for R2 to be evaluated. Responsible party agreed to provide one on one companion.. S1 was removed from the floor the same day and provided with a write up and on 12/16/2021 S1 was terminated due to this incident, Administrator provided termination letter dated 12/16/2021.

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: 02/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BROOKDALE NAPA
FACILITY NUMBER: 286800493
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2022
Section Cited

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87465 (a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. Facility staff failed to give residents' their medications as ordered/prescribed by the Physician. This requirement has not been met as evidence by:
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Based on records review and interviews R2 received the wrong medication for anxiety and received another resident's medication in error by med-tech on duty. R2 was monitored by staff for any adverse reactions from receiving the wrong medication.
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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: 02/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2022
LIC809 (FAS) - (06/04)
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