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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 03/18/2021
Date Signed: 04/05/2021 07:50:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 NAPAFACILITY NUMBER:
286800493
ADMINISTRATOR:STEVEN MATTINGLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 70DATE:
03/18/2021
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ed Silva/Regilyn Balliao/Angela DomingoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Angela Elliott held a tele visit with Ed Silva, Director of Operations, Regilyn Balliao, Regional Resident Services Director and Angela Domingo, Manager of Carebridge Memory Care Unit to review incidents. Tele-visit was held due to COVID-19 precautions. LPA requested documentation.

LPA received an SOC 341 on 3/05/2021 for an incident occurring on 3/04/2021. Staff discovered R1 and R2 grabbing at each other and yelling in the bathroom. Staff intervened, R1 and R2 were redirected and no injuries were sustained. R1 had a previous altercation with a resident on 2/24/2021. Since the incidents R1 has moved to a new apartment and staff are making sure R1 is out of their room more to be engaged in activities. R1’s physician also did a medication increase which seems to have been effective as R1 is calmer and there have been no further unwanted interactions.

LPA also reviewed incident with R3 who was discovered at a local restaurant on 3/11/2021 and the facility was contacted by the police. The facility thinks R3 walked to the restaurant as it is a block away. Staff picked up the and resident, resident was assessed with no injuries. R3 did not remember that they lived at the facility. Previously R3 needed assistance with medication management. R3 now has a 1:1 caregiver and is getting a new physician's assessment to determine if they need to move to a memory care setting.

LPA and Operations Specialist discussed the importance of ensuring incident reports are sent in during the required time frame per regulation.

No citations for deficiencies issued at this time.

Signature on File.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2021
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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