286800493-4-12-2022-21-AS-BMOS-CDFU2K-20220413151200

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 04/12/2022
Date Signed: 04/12/2022 10:59:27 AM

Unsubstantiated

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
03/18/2022 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220318151944

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:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Kim Humphrey (Administrator)		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff is not allowing authorized representative to view resident records.

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 alleged that Staff is not allowing authorized representative to view resident records resident. Per reporting party, resident (R1) was admitted to this facility on September 2021 and died on January 2022. During residence in the facility R1 went to the hospital four times due to behaviors and once for a fall. On December 28, 2021 R1 was rushed to the emergency room and passed away on 1/2/22 due to pneumonia. Reporting party has been trying to obtain R1’s records from the facility, but the records have not been available for review. During interviews LPA was informed by administrator that the facility has mailed R1’s records to responsible party address on file. However, there was no proof that documents were mailed to the address on file and Administrator re-mailed them through certified mail.

Continue 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: 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)

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Control Number 21-AS-20220318151944

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...

Based on contradictory information received from Administrator and reporting party, LPA was unable to either prove or disprove the above allegation. The investigation revealed that only two hospitalization incidents dated 12/10/21 and 12/11/21 were reported to the Department. LPA has issued a citation addressing reporting requirements in March 2022 and Administrator acknowledged regulation. A finding that the complaint allegation “Staff is not allowing authorized representative to view resident records” 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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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)

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