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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801070
Report Date: 02/15/2024
Date Signed: 02/15/2024 04:02:57 PM


Document Has Been Signed on 02/15/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 54DATE:
02/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator, Mary SchrammTIME COMPLETED:
04:15 PM
NARRATIVE
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At approximately 1:50PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection on an Incident Report that was received by CCL on 01/17/2024 and occurred on 01/16/2024. LPA met with Administrator, Mary Schramm, and discussed the purpose of the visit.

Incident report states that Resident 1 (R1) went out the facilities front door at 10:57AM, and the front desk clerk let the Medication Technician know that R1 was leaving. Staff proceeded to search for him but were unsuccessful, so after 20 minutes of searching they called the police for assistance. R1 was eventually located by a Community Service Officer in the the locked Yacht Club at 12:14PM and was then brought back to the facility. Resident had no injuries.

Per conversation with Administrator, R1 is ambulatory and moves quickly. R1's Physicians Report states that R1 has a Dementia DX. Physicians Report has conflicting information, with one section indicating that R1 is not at risk if allowed to leave the facility unsupervised, and another section indicating that R1 is at risk if allowed to leave the facility unsupervised. Review of R1's care plan dated 11/03/2023, indicated that it is required that R1 wears a wanderguard at all times. R1 was placed on frequent 2 hour status checks. It was noted in R1s care plan that R1 is unable to leave the facility unassisted.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.



Exit interview conducted. Copy of report, LIC809D, and appeal rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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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Document Has Been Signed on 02/15/2024 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: MEADOWS OF NAPA VALLEY, THE
FACILITY NUMBER: 286801070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia
(j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Facility conducted an all staff retraining, increased supervision was implemented, and a 1:1 companion has been put in place for resident. Deficiency cleared during visit.
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Based on interview and record review, the licensee did not comply with the section cited above by allowing resident to exit the building unassisted, resulting in resident elopement.
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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) 588-5040
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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