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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 03/15/2021
Date Signed: 03/16/2021 09:03:37 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210104085521
FACILITY NAME:BROOKDALE NAPAFACILITY NUMBER:
286800493
ADMINISTRATOR:STEVEN MATTINGLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 70DATE:
03/15/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ed Silva, Interum AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident was issued a level of care fee increase without proper notification.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Ed Silvathis date for the purpose of delivering findings on the above-captioned complaint allegation. The visit was conducted via tele-visit due to the Covid-19 precautions. LPA did not physically present at the site. It has been alleged that fees for services were increased for R1 in the fall of last year without written notification of the increase which is required by the Facility Admission Agreement. During the course of this investigation, this Department has taken statements from witness and staff and obtained and reviewed records. Based upon the statements taken and records reviewed, the following determiniations have been made: Fees for services were incereased for R1 in the fall of last year; Administration acknowledges that no written notice of the increase was provided to R1 or R1's Responsible Person, although verbal discussions of the increase did occur. Based upon statements taken and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
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-20210104085521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: BROOKDALE NAPA
FACILITY NUMBER: 286800493
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2021
Section Cited
CCR
87507(f)
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Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. ***Based upon statements and records, this requirement has not been met as evidenced by: Fees for services were increased for R1 without the required
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Administration to submit to CCL a plan that addresses how the facility will meet the requirement of providing written notification of fee increases going forward. Plan to be submitted by POC date in order to clear the deficiency.
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written notification. This posed a potential risk
to the personal rights of R1.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/04/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210104085521

FACILITY NAME:BROOKDALE NAPAFACILITY NUMBER:
286800493
ADMINISTRATOR:STEVEN MATTINGLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 70DATE:
03/15/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ed Silva, Interum AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident is being charged for services not provided.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Ed Silva this date for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele-visit due to the Covid-19 precautions. LPA did not physically present at the site. It has been alleged that R1 has been charged for services not received. Services include medication management and bathing, etc. During the course of this investigation, this Department has taken statements form witnesses and staff and obtained and reviewed records. Based upon the statements taken and records reviewed, the following determinations have been made: Physician's assessment dated September 2019, is ambivalent and indicates that R1 can manage only some of the tasks involved in medication management; Facility medication management assessment of 11/05/2020 suggests that R1 needs assistance 4 of the 22 tasks involved in medication management; Staff report R1 refuses assistance with activities of daily living on occasion; Records reviewed indicate intermittent refusal of services for ADL's by R1. Although the allegation may be true, based upon statements and records reviewed, there is not a preponderance of evidence to prove violation did, or did not, occur. Therefore, the allegation is deemed UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021
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 3