286800493-2-24-2022-21-AS-BMOS-CC5SUH-20220302131106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 02/24/2022
Date Signed: 02/24/2022 10:41:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/01/2022 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220201125459

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: 67	DATE:	02/24/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Kim Humphrey (Administrator)		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Faciltiy not following physician's medicaiton orders

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 facility not following physician’s medication orders. Reporting party alleged that staff did not place a refill order for resident (R1) narcotic pain medication. Based on records review conducted at the facility on 2/7/22. Facility provided R1’s Physician order effective October 4, 2021 indicating that R1 had a medication change to Hydrocodone-acetaminophen (NORCO) 4 times a day (8am, noon, 4pm and 8pm) due to chronic pain due to injury. On Saturday 1/29/22 facility care notes indicated that R1 missed their Hydrocodone-acetaminophen dosage at 8pm the night before due to facility did not have medication on hand. The fax cover sheet dated 1/29/22 revealed that the request to the pharmacy was submitted on 1/29/22 at 5:31am.
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: 02/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220201125459

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/25/2022 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 (a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	Administrator agrees to conduct a medication audit for all residents, retrain staff on medication management & will write a plan to ensure resident medications are managed & residents do not run out of medications. Administrator will submit the updated plan to CCL by POC due date.
	8 9 10 11 12 13 14	Based on observation, records review & interviews Administrator did not ensure proper management of medication for R1. Facility staff did not have R1’s prescribed medication order since 1/29/22 through 2/1/22 which poses an immediate health & safety risk to resident in care.	8 9 10 11 12 13 14	Civil Penalties issued today in the amount of $250.00 for repeated violation during visit on 2/7/22.
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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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220201125459

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 02/24/2022

NARRATIVE

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Continued from LIC9099...

On 2/1/22 at 1:19pm LPA conducted confidential interviews that revealed that responsible party was able to obtain a triplicate of the hard copy to be brought back to the pharmacy for dispensing the Norco medication for R1. R1’s physician report dated 9/1/2020 and personal service plan dated 12/1/2020 until the present indicates that facility is responsible for R1’s medication management including order, coordination, storage and assistance with medications. During confidential interviews with facility staff this information was confirmed. LPA reviewed incident report logs that were submitted to CCL and this incident was not submitted to CCL 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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022

LIC9099 (FAS) - (06/04)

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