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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 05/17/2022
Date Signed: 05/17/2022 12:10:07 PM


Document Has Been Signed on 05/17/2022 12:10 PM - It Cannot Be Edited

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: 66DATE:
05/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Kim Humphrey (Administrator)TIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Executive Director (Administrator), Kim Humphrey to conduct a case management visit regarding a recently self-incident reports (SIR) along with SOC341s which resulted in a suspected physical abuse. SIR report was submitted to CCL on 5/2/22 and 5/9/22.

The incident occurred on 4/29/22 at approximately 7:30pm agency caregiver (I1) went to staff (S1) to report a witnessed alleged physical abuse of two facility residents (R1 and R2) by another agency caregiver (I2). I2 grabbed R1 and R2's arm and pushed them in the direction of I2's preference in an abusive way. S1 notified Health and Wellness Coordinator and Executive Director about the incident and I2 was sent home immediately and has not returned to work at the facility. S1 left a voicemail to Acclaim Home Care to notified them about the incident. Both residents were assessed and no apparent injury, bruising or physical signs of abuse was observed. During today's visit LPA was provided with a copy of written statements from I1 and I2 describing the incident. LPA also learned that both residents are currently residing at the memory care unit and no concerns had been raised by their responsible parties. Based on interviews conducted by Administrator with staff, the allegation is probably not substantiated. The facility is in the process of finishing up the investigation report and agreed to provide a copy to CCL by not later than 5/20/22.

Another incident involving resident R3 and R4 occurred on 4/30/22 at approximately 1:45pm when resident R5 called staff (S2) to assist R3 from R4 because R4 was hitting R3 on their head. S2 checked R3's head for injury and noted some redness. However, R3 did not need to receive medical treatment. Responsible parties were notified. During today's visit, LPA conducted interviews and obtained documents including care plan assessment dated 10/28/21 indicating that R4 needs to have additional staff involvement due to demonstrating behaviors such anxiety, disruption or obsessive behaviors requiring additional attention. Based on interviews conducted with Administrator and staff, R4's behaviors have been worsening and responsible party have scheduled a doctor's appointment to address this behaviors. The facility will update R4's care plan after doctor's visit. No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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