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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 03/23/2022
Date Signed: 03/23/2022 12:54:50 PM



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
01/24/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220124082048
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: 67DATE:
03/23/2022
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Kim Humphrey Administrator)TIME COMPLETED:
01:05 PM
ALLEGATION(S):
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-Authorized representative was not provided an itemized bill for service fees increase.
-Facility does not have sufficient staff to meet the needs of residents in care
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 authorized representative was not provided an itemized bill for service fees. Reporting party alleged that there was a care increase that occurred on 12/20/21 from $833 to $3075 reflected on resident’s (R1) bill for the month of January 2022 and staff did not notify responsible party about this change. Based on records review conducted at the facility on 1/28/22. Facility provided R1’s residency agreement dated 9/30/20 indicating that facility will provide rate change notices in writing 60 days prior to the increase to their responsible parties. Administrator provided care increase letter dated 10/21/21 that was served to R1 at their facility unit indicating increases that will be effective January 1, 2022. During LPA’s interviews conducted with Administrator acknowledges that no written notice was provided about care increase nor discussed the changes with R1’s responsible party.
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: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
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 3
Control Number 21-AS-20220124082048
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: 03/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/24/2022
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 hiring permanent staff. Administrator agrees to submit a written plan in how the facility will ensure that resident’s needs are being met daily and staff will respond to call system in a timely manner to CCL by POC due date. **Civil Penalty assessed in the total amount of $250.00 for repeated violation during visit on 12/10/21.
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Based on records review of alarm response report, staff schedules for the month of January 2022 and interviews conducted with staff on duty, Administrator did not ensure that facility had sufficient number of staff to meet residents needs which poses an immediate risk to the health and safety of residents in care.
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Type B
03/30/2022
Section Cited
CCR
87507(g)(4)
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Type B 87507 Admission Agreements (g) Admission agreements shall specify the following: (4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change…This requirement has not been met as evidence by:
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Administrator has offered a total credit to R1’s responsible party in the amount of $2617.74 for the period between December 20, 2021 to January 24, 2022. The credit will be over 6 months at $436.29 a month and any late fee for January will be waived as well.
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Based on records review and interviews with Administrator did not ensure that R1’s responsible party was provided an itemized bill for care service increase fees as stated by facility admission agreement which poses a potential risk to the health and safety of residents in care.
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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: 03/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20220124082048
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: 03/23/2022
NARRATIVE
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Continued from LIC9099...

Administrator provided an email sent to R1’s responsible party dated 1/28/22 at 6:29pm confirming this information and offering a total credit in the amount of $2617.74 for December 20, 2021 to January 24, 2022. The credit will be over 6 months at $436.29 a month and any late fee for January will be waived as well. Administrator also provided R1’s assessment summaries performed every 6 months since 12/1/2020 to the present indicating R1’s changes of condition. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

It was also alleged that Facility does not have sufficient staff to meet the needs of residents in care. Reporting party alleges that the facility often operates with limited caregivers, but the facility is asking for an increase in fees. On 1/31/22 R1 smelled very strong odor of urine, reporting party asked R1 when was the last day that they had a shower and R1 replied forty-eleven Sundays ago. Based on records review and confidential interviews with Administrator the facility has been experience a shortage of staffing due to the pandemic and temporary staffing agencies had been contacted to bring staff on shift to meet resident’s needs. LPA obtained staff schedules for the Memory Care Unit for the month of January 2022 with a census of 17 residents in care revealed that on the following dates and times 1/3/22 between 2pm-6pm; 1/6/22, 1/10/22, 1/11/22, 1/13/22 and 1/17/22 between 10:30pm-6:30am there was only one caregiver on duty. On 3/21/22 LPA conducted confidential interviews with Memory Care Unit staff from different shifts confirmed that there had been times where they have worked alone during their shifts. Sometimes, they also get some help from Med-technicians. Per Administrator, she doesn’t allow staff to work alone and there had been times that her Wellness Director stayed later at nights to help with floor coverage. However, facility provided alarm response reports dated 1/23/22 to 1/27/22 indicated that staff response times to help residents in care were over 20 minutes as following: 8 times on 1/23/22; 21 times on 1/24/22; 7 times on 1/25/22; 8 times on 1/26/22 and 2 times on 1/27/22. Per Administrator, there was an error that the facility could not provide call response log for the dates between 1/28/22 to 1/31/22 due that they could not go back further because the system did not allow it, but ensures that there was a staff meeting about response times and there was a staff who was terminated because was taking more than normal helping residents in care. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.
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: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3