<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286800493
Report Date: 06/29/2021
Date Signed: 07/01/2021 10:46:13 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:HUMPHREY, KIMBERLYFACILITY TYPE:
740
ADDRESS:3255 VILLA LNTELEPHONE:
(707) 252-3333
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:108CENSUS: 64DATE:
06/29/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kimberley HumphreyTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Elliott conducted a case management visit to follow up on concerns revealed to Community Care Licensing (CCL) regarding facility surveillance testing and staffing. LPA met with Kimberley Humphrey, Executive Director. LPA was screened for COVID-19 upon arrival. Executive Director indicated they are still waiting for COVID-19 mitigation plan and will request it from Supervisor this afternoon. Executive Director indicated they are actively hiring and surveillance testing is ongoing per CCL requirements. LPA also followed up regarding Plans of Correction (POC)'s from a citation issued on 5/6/2021 related to complaint number 21-AS-20210304083733. LPA determined the following deficiencies are still outstanding:
  • 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...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.

  • 87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency within 7 days... 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.

  • 87208 - Plan of Operation: 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.

LPA and Executive Director agreed plans of correction will be submitted to LPA by 7/15/2021. LPA will e-mail citations to Executive Director. No citations issued for deficiencies at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1