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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 03/29/2021
Date Signed: 04/05/2021 07:50:38 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:
03/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ed Silva/Regilyn BalliaoTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Angela Elliott held a tele visit with Ed Silva, Director of Operations and Regilyn Balliao, Regional Resident Services Director to review incidents. Tele-visit was held due to COVID-19 precautions. LPA requested documentation.

CCL received incident report on 3/26/2021 for incident occurring on 3/19/2021 when R1 entered R2's room and they had an altercation. When staff came to assist, R1 was on the floor with R2 holding onto R1. R1 sustained a skin tear to right forearm and first aid was provided. According to Ed R1 was confused and asked R2 to leave their room. Staff are getting R1 involved in more activities to prevent a potential altercation again.

CCL received incident report on 2/19/2021 for incident occurring on 2/2/2021 where R3 requested to go to the hospital due to left arm numbness and left side rib pain. 911 was called and R3 was assessed at Queen of the Valley Hospital. There is no further information on the incident report. Ed indicated R3 sustained multiple rib fractures. No surgery was required and R3 is doing well with their walker and pain management regimen. LPA discussed an incident report was not received for R3's fracture, and the importance of reporting to CCL within regulatory regulations. Ed indicated one would be sent to CCL.

No citations issued for deficiencies. Signature on file.













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

DATE: 03/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021
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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