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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801070
Report Date: 07/30/2020
Date Signed: 07/30/2020 03:55:57 PM

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:MEADOWS OF NAPA VALLEY, THEFACILITY NUMBER:
286801070
ADMINISTRATOR:PANCHESSON, WAYNEFACILITY TYPE:
741
ADDRESS:1800 ATRIUM PARKWAYTELEPHONE:
(707) 257-7885
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:350CENSUS: 296DATE:
07/30/2020
TYPE OF VISIT:Case Management - IncidentANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary SchrammTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Angela Elliott met with Mary Schramm, Administrator for a case management tele-visit. It is being conducted via tele-visit due to COVID - 19 precautions.

LPA conducted interview. Facility self reported on 7/23/2020 R1 attempted suicide. Per Care Plans R1 was put on Hospice on 6/26/2020. Staff entered R1's room to bring dinner, staff noticed bloody knife and cut on R1's neck. R1 indicated their actions were in order to end their life. Facility immediately contacted 911, Napa Police Department was also involved. R1 was held at the hospital and discharged to facility on 7/28/2020. R1 now has a one-to-one 24-hour caregiver.

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: 07/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2020
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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