286800493-5-28-2021-21-AS-BMOS-C3LNTQ-20210602104507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286800493
Report Date: 05/28/2021
Date Signed: 05/28/2021 12:49:24 PM

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
02/10/2021 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210210121305

FACILITY NAME:	BROOKDALE NAPA		FACILITY NUMBER:	286800493
ADMINISTRATOR:	STEVEN MATTINGLY		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LN		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	108	CENSUS: 86	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Kimberly Humphrey		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.
Staff handled resident roughly
Facility staff did not observe changes in resident's physical condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via tele-visit with Kimberly Humphrey, Executive Director for the purpose of delivering findings for above allegations. It is being conducted by tele-visit due to COVID - 19 precautions.

There is an allegation resident sustained pressure injuries while in care. Residential Care Summary documentation for R1 dated 4/6/2021 does not reflect treatment for pressure injuries. R1 moved from facility to another facility (Facility A) on 3/3/2021 and then to another facility (Facility B) on 3/8/2021. LPA interviewed Facility A’s Administrator on 3/17/2021 who indicated R1 had no evidence of past pressure injuries or healing pressure injuries when admitted. LPA interviewed Administrator for Facility B on 3/16/2021 who indicated R1 had no physical issues such as pressure injuries when admitted. .

(See LIC 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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-20210210121305

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: 05/28/2021

NARRATIVE

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E-mail dated 5/19/2021 from outside Home Health Agency indicates R1 did not receive wound care service. R1 was interviewed on 5/14/2021 and they indicated they had not sustained pressure injuries. Based on LPAs interviews, observation and record review it has been determined the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis

There is an allegation staff handled resident roughly. LPA was unable to obtain sufficient evidence or witnesses that R1 was handled in a rough manner. LPA also interviewed R1 on 5/14/2021 did who denied being handled roughly. Based on LPAs interviews, observation and record review it has been determined the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

There is an allegation facility staff did not observe changes in resident's physical condition. LPA spoke with Operations Specialist on 2/18/2021 who confirmed R1 went to Kaiser Vallejo on 2/11/2021 to be assessed for symptoms related to COVID and came back on 2/15/2021. Interview with R1 on 5/14/2021 confirmed when they started to feel bad the facility sent them to the hospital. Based on LPAs interviews, observation and record review it has been determined the allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
02/10/2021 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210210121305

FACILITY NAME:	BROOKDALE NAPA		FACILITY NUMBER:	286800493
ADMINISTRATOR:	STEVEN MATTINGLY		FACILITY TYPE:	740
ADDRESS:	3255 VILLA LN		TELEPHONE:	(707) 252-3333
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	108	CENSUS: 86	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Kimberly Humphrey		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff did not observe changes in resident's physical condition
Food served is not of the quality to meet the resident's needs
Staff did not ensure resident's bed had clean linens.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Elliott made contact this date, by phone, with Kimberly Humphrey, Executive Director for the purpose of delivering findings for above allegations. It is being conducted by tele-visit due to COVID - 19 precautions.

There is an allegation facility staff not assisting resident with ADLs (Activities of Daily Living). LPA interviewed R1 on 5/14/2021 who indicated there were delays in getting care. Multiple interviews with staff and residents confirm residents do get assistance with ADL’s, but the response time is delayed. Please also refer to Complaint 21-AS-20210126151235. 1 out of 6 residents interviewed indicated they did not get assistance with ADL’s for three days. Based on LPA interviews, record review and observation although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.

(See LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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 4

Control Number 21-AS-20210210121305

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: 05/28/2021

NARRATIVE

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There is an allegation food served is not of the quality to meet the resident's needs. LPA virtually toured facility kitchen on 4/22/2021. Food observed was of good quality and a sufficient amount for facility census. Facility menus were posted with a variety of choices. Interviews with staff and residents revealed food is readily available and there are several choices offered for each meal every day. Interview with R1 on 5/14/2021 indicated the food was pretty good and the kitchen staff were helpful but the quality went downhill after COVID. Interview with S1 affirmed if a resident misses a meal there is always food on hand with morning snacks and evening snacks. Input is gathered from the residents through a suggestion logbook and individual comment cards. These are reviewed with the staff so the facility can do better, and dining staff have meetings with the residents. Based on LPA interviews, record review and observation although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.

There is an allegation staff did not ensure resident's bed had clean linens. Operations specialist explained during interview on 4/22/2021, towels and linens are usually done once a week or as needed for incontinence needs. Personal laundry is done once a week and as needed for incontinence; PM shift gathers laundry NOC shift washes laundry and AM shift puts laundry away. Interviews with residents reveal the Housekeeping and laundry services were good but recently changed. During interviews it was expressed the new system is inefficient for personal laundry but housekeeping is good about changing linens and towels. When interviewed on 5/14/2021, R1 could not confirm they had been left in linens covered in feces and urine. Based on LPA interviews, record review and observation although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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