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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801070
Report Date: 07/03/2024
Date Signed: 07/03/2024 06:30:09 PM


Document Has Been Signed on 07/03/2024 06:30 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: 328DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Kristine Soriano, Resident Services and Independent Living Director & Mary Schramm, AdministratorTIME COMPLETED:
06:45 PM
NARRATIVE
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At approximately 8:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection. Kristine Soriano, Resident Services and Independent Living Director was contacted and arrived at approximately 8:50 AM. Facility is an Continuing Care Residential Community (CCRC) with 328 residents in care. Community has a Hospice waiver for 15 with 4 residents currently receiving Hospice services.

At approximately 9:10 AM, LPA initiated a tour of independent living facility with Director and observed the following: Facility has a two- and a three-story wing, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients.
At approximately 10:15 AM, LPA initiated tour of the assisted living and memory care facility with Mary Shcramm, Administrator of Assited LIving and Memory Support. The Assisted living wing is a two stories and memory care in one story. The facility was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. Cabinets containing cleaning supplies and other items that could pose a risk were locked. The community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered patio, seating area and outdoor space for activities. LPA observed an activity schedule and a facility computers and internet available for resident use.

LPA reviewed medications and medication records which are maintained in compliance with regulation.

Continued on LIC809-C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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 07/03/2024 06:30 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: 07/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)


This requirement is not met as evidenced by:
Care of Persons with Dementia 87705(c)(5) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: [….] Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 10 resident files reviewed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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Licensee to submit a current medical assessment and reappraisal care plan for R1-R4 to CCLD by POC due date 7/31/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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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
VISIT DATE: 07/03/2024
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Continued from LIC809...

The community's fire extinguishers were observed charged and were last serviced January 2024. Smoke and Carbon Monoxide detectors were observed during inspection.

Facility conducts regular bi-annual emergency/disaster drills, and LPA informed Director and staff that these shall be completed quarterly moving forward per regulation. The community's most recent drill was conducted June 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated April 2016. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community. Facility has a three backup generators.

At approximately 1:30 PM, LPA reviewed ten (10) staff files and ten (10) resident files. Ten (10) of ten (10) staff files reviewed has the required current First Aid certificate and each has a current CPR certification as well. Each staff file reviewed had all the required paperwork per regulation. Four (4) of ten (10) resident files reviewed were missing the required updated annual physicians report and updated and signed reappraisal and care needs plan. LPA issued a citation for this (see LIC 809D). LPA observed all the remaining required paperwork in all ten (10) resident files reviewed. Administrator informed LPA that community coordinates medical and dental visits for the majority of their residents.

LPA also obtained documents regarding recent IRs and SOC341 during inspection and will follow up with community at a later date.

Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:



LIC500- Personnel Report
LIC610- Emergency Disaster Plan
A copy of community Liability Insurance
A copy of the property deed - proof of ownership

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 with Administrator and Appeal rights were given. Signature on form confirms receipt.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024
LIC809 (FAS) - (06/04)
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