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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 05/06/2021
Date Signed: 05/06/2021 09:28:05 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
03/04/2021 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210304083733
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: 63DATE:
05/06/2021
UNANNOUNCEDTIME BEGAN:
08:30 PM
MET WITH:Ed SilvaTIME COMPLETED:
08:45 PM
ALLEGATION(S):
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Resident sustained multiple falls while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Angela Elliott made contact on this date, by phone, with Operations Specialist Ed Silva for the purpose of delivering complaint findings for allegation listed above. It is being conducted via phone due to COVID-19 precautions.

Based on multiple interviews with staff it was confirmed R1 had multiple falls between 5/20/2020 and 1/31/2021. According to Area Health & Wellness Director, R1 who resided in the Assisted Living portion of the facility had a fall on the following dates: 5/21/2020, 5/23/2020 , 6/30/2020, 7/2/2020, 7/3/2020, 7/19/2020, 11/6/2020, 11/17/2020, 1/28/2021, and 1/31/2021.

Documentation revealed examples of R1’s change in mental status. Post fall evaluation dated 5/31/2020 for fall on 5/21/2020 and post Evaluation fall dated 7/29/2020 for fall occurring on 6/30/2020 reflected a change in medical cognitive status as a risk factor. Post Fall Evaluation dated 5/31/2020 for fall on 5/23/2020 reflects compliance with safety issues and change in ability to transfer/ambulate (gate disturbance or decreased mobility) as risk factors for fall. For falls on 5/21/2020, 5/23/2020, and 6/30/2020 Service plan Interventions reflect- PSA/PSP reviewed but no changes. Post Falls Assessment dated 7/30/2020 for fall on 7/2/2020
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
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 4
Control Number 21-AS-20210304083733
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
VISIT DATE: 05/06/2021
NARRATIVE
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reflects Environmental factors as risk factors for fall. Post Falls Assessment dated 7/30/2020 for fall on 7/2/2020 reflects compliance with safety issues as risk factor for fall. Post Fall Evaluation dated 7/29/2020 for fall on 7/19/2020 reflects change in ability to transfer/ambulate (gait disturbance or decreased mobility) as risk factor for fall. For fall on 7/2/2020 and 7/29/2020 Service plan Interventions reflect Resident placed on alert charting and staff to observe for any change in condition and report to the HWD or MT on duty. None. PSA/PSP reviewed but no new changes. Post Fall Evaluation dated 12/12/2020 for fall on 11/6/2020 reflects compliance with safety issues as risk factors for fall. Service plan Interventions reflect- PSA/PSP reviewed but no changes. Personal Service Plan (PSP) dated 8/4/2020 under Escort and Mobility section discuses fall on 5/21/2020 and 5/23/2020, and reflects-7/24/2020 R1 has been unable to walk with their walker and is now using a wheelchair. Staff to assist R1 to and from the dining room and activities of choice. Staff to assist R1 as needed with wheelchair mobility. Care Plan dated 8/4/2020 reflects resident is a fall risk with no substantial change developed to minimize risk for falls. Multiple staff interviews and interviews with outside parties revealed R1 was increasingly confused which contributed to falls. CCL received incident reports for falls occurring on 6/30/2020 and 7/19/2020. Post-fall investigation and care plans reviews were not completed per facility’s Falls Management Policy CS-30-14, as well as Clinical Guidelines for Fall Prevention and Management-32. R1 was admitted to the hospital with COVID due to multiple falls on 1/31/2021 and stayed in the hospital until 2/17/2021. R1 no longer resides in this community. Based on LPA observations, interview and record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given to the Administrator. Exit interview was conducted and a copy of this report was emailed to the Administrator for signature.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20210304083733
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: 05/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2021
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency within 7 days of the occurrence of…(D) Any incident which threatens the welfare, safety or health of any resident. This requirement was not met as evidenced by:
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Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator agrees to review regulation and conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date of 5/20/2021.
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Based on LPA’s records review and interviews conducted Administrator/Licensee did not ensure that CCL was notified regarding trend of falls with R1 which poses a potential health & safety risk to residents in care.
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Type B
05/20/2021
Section Cited
CCR
87208
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87208 - Plan of Operation: This requirement is not met as evidenced by:
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Administrator will ensure facility procedures and protocols are followed. Administrator agrees to submit plan to ensure Falls Management Policy CS-30-14, as well as Clinical Guidelines for Fall Prevention and Management are followed by POC date of 5/20/2021.
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Administrator/Licensee did not ensure facility protocols and procedures were followed. Administrator/Licensee did not ensure post fall evaluations were completed for R1 which poses a Health & Safety risk to residents in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20210304083733
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: 05/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2021
Section Cited
CCR
87463(c)
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87463 Reappraisal. (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff,...when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, This requirement is not met as evidenced by:
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Administrator/Licensee to ensure that Appraisals and care plans are completed upon admission and reappraisals are done as frequently as necessary for all residents to ensure that resident is receiving the appropriate level of care.
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Based on resident file review Administrator/Licensee failed to ensure that R1 had reappraisal when there was a change of condition which poses a potential health and safety risk to residents.
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Administrator agrees to submit a plan to ensure all residents personal service plans reflect current conditions and needs to CCL by POC date of 5/20/2021.

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

DATE: 05/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4