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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 04/12/2022
Date Signed: 04/12/2022 11:27:06 AM

Substantiated


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
02/15/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220215153234
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:
04/12/2022
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Kim Humphrey (Administrator)TIME COMPLETED:
11:40 AM
ALLEGATION(S):
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-Insufficent Staffing.
-Facility is not meeting Resident's needs.
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 facility has insufficient staff. Per reporting party, On 2/6/22 resident (R1) was observed with brief upside down and inside out, pressed the call button and waited long time for a staff, asked them if they know how they are supposed to transfer R1, if they need 2 staff for transfers and med-tech on duty stated that they were short staffed and no one available to train or observe transfer strategies. Per medical records obtained, on 2/9/22 there was no staff to train for foot care. Also there had been times where R1 has been left in bed for three days at a time and there is just enough staff working on the weekend to care for the number of residents in care. Based on records review provided by the facility, sign-in sheet dated 2/17/22 a training on “Drive lift for R1 training for two person transfers” was conducted with only one staff and second training was conducted on 3/10/22 with five staff.
Continue 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: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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 5
Control Number 21-AS-20220215153234
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: 04/12/2022
NARRATIVE
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Continued from LIC9099...

Although R1’s assessment summary dated 1/27/22 revealed that facility will provide and charge effective 2/1/22 $1454 two people assist or a mechanical lift to help R1 with transfers. LPA obtained staff schedules for the Assisted Living Unit for the month of February 2022 with a census of 49 residents in care indicates that the facility had an average of two to three caregivers on duty for residents in care. However, On 2/6/22 there was only one caregiver on duty; Alarm response reports dated 2/1/22 to 2/24/22 indicated that staff response times to help R1 were over 20 minutes as following: on 2/1/22-1 time, 2/6/22-1 time, 2/7/22–7 times, 2/9/22-1 time, 2/11/22-2 times, 2/12/22-1 time, 2/14/22–3 times, 2/17/22-2 times, 2/19/22-1 time, 2/20/22-1 time and 2/24/22-4 times. Per Administrator, there was a staff meeting about response times. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Regarding allegation “Facility is not meeting Resident's needs”. Per Reporting party, R1 was observed on different dates (2/6/22, 2/9/22, 2/22/22) soiled, not clean from feces, has not had a shower and there are concerns that R1 was assessed and placed at inappropriate level of care. Based on records review provided by the facility dated 2/24/22 at 8:38am there was an email sent to the Administrator by R1’s responsible party raising concerns about R1’s level of care and services assessed by the facility not being provided including showers twice a week, dressing, grooming, bathroom assistance and escorting. In this email, there is a reference to repeated findings of R1 been soiled, dirty and times where resident had been left in bed for three days at a time resulting in R1 developing Urinary Tract Infection (UTI). Also, on 2/19/22 around dinner time when staff brought R1’s dinner and left it on a counter in their room, R1 told the staff to please bring it closer to their bed because R1 is unable to get up and walk over to the counter to get the dinner and staff just left the room. Based on records review, discharge documents dated 2/16/22 revealed that R1 has a diagnosis of UTI. During records review provided by the facility, there is a doctor’s note dated 2/7/22 indicating that R1 was recommended to be transferred to the Memory Care unit where they can receive total care as necessary and facility correspondence records indicated that they are in the process of coordinating an appointment with R1’s responsible party to discuss about the possibility to move R1 to the Memory Care unit. Facility also requested a new Physician report (LIC602) with changes because old report dated 12/23/21 doesn’t reflect current R1’s medical and mental status. On 2/24/22 LPA conducted interviews with Health and Wellness Director who stated that R1 has not been taking a regular shower because R1 is a two people assist and staff had not been trained yet to use Hoyer lift, but they have been offering a bed sponge bath and R1 has refused. However, they will take resident to walk-in bathroom located in the memory care unit and see if resident would like to take a shower there using a shower chair. 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. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns and overall compliance of the facility.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
02/15/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220215153234

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:
04/12/2022
UNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Kim Humphrey (Administrator)TIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Resident Room is not furnished per regulation
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 that “Resident Room is not furnished per regulation”. Reporting party has concerns regarding Resident’s (R1) deficit in functional mobility including bed mobility including transfers and ambulation. Per Reporting Party, Resident (R1) has moved to the facility since 2/2/22 and R1’s hospital bed was provided by Apria who is an outside vendor from Kaiser, the bed was broken at that time and bed rails had been removed by the facility due to facility policy. However, the bed would not raise up and down; Reporting party inquired with facility staff about it and was told that R1 refused the new bed. Also, R1 has a phone in the room but across the room where they could not reach or get and was not working due to their responsible party had to set up the TV and phone service. However, there was limited access to the facility due to Covid19 protocols in place. R1 had plastic drawers with personal items that were not next to the bed.
Continue on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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-20220215153234
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: 04/12/2022
NARRATIVE
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Continued from LIC9099A...

During interviews with Administrator, LPA was provided with facility “restraints policy” dated 9/1998 indicating on item#2: “full side rails and/or half side rails are not permitted” instead the residents are allowed to use a “halo” and the facility provided proof that they are in the process of coordinating this service with R1’s responsible party. Based on records review, rental agreement dated 2/1/22 at 6:56:13 a semi-electric bed was delivered to facility address. Per Administrator, “Beginning of February a new hospital bed was being delivered but R1 refused to have the gentleman deliver the bed and Administrator went to talk to resident to encourage them to get the new bed placed but R1 refused. The week of 2/13/22 the bed was fixed temporary and Health and Wellness Director reached out to Apria to see if they could deliver bed again and a new bed was delivered on 2/18/22 and no invoice was provided because they delivered after hours”. On 2/24/22 LPA toured R1’s room and observed two dresser with three drawers, there was a chair, three plastic drawers next to R1’s bed containing incontinence care supplies, the tv was on and phone was working, Hoyer lift located in R1’s room had plastic wraps around it and was not in use, bed functions were working properly. Based on observations, interviews and records review resident room was observed furnished per regulation. A finding that the complaint allegations “Resident Room is not furnished per regulation” 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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20220215153234
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: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
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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Administrator was informed that the Dpt will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility. Administrator agrees to submit a training date for all staff in how staff will respond to call system in a timely manner to CCL by POC due date.
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Based on records review of alarm response report, staff schedules for the month of February 2022 and interviews conducted with staff, Administrator did not ensure that staff on duty was sufficient to respond in a timely manner to call system to help residents in care which poses an immediate risk to the health and safety of residents in care.
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 **Civil Penalty assessed in the total amount of $250.00 for repeated violation during visit on 3/23/22.
Type A
04/13/2022
Section Cited
HSC
1569.269(a)(6)
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§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:
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Administrator was informed that the Dpt will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility. Administrator agrees to submit a written plan to ensure facility is following up on residents’ needs by POC due date
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Based on LPA observation, interviews and records review, the facility staff did not ensure that R1 was assisted in a timely manner by staff resulting on R1 developed a UTI which poses an immediate risk to the health and safety of residents in care.
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 **Civil Penalty assessed in the total amount of $250.00 for repeated violation during visit on 12/11/21.
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: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5