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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801070
Report Date: 08/15/2024
Date Signed: 08/15/2024 11:17:48 AM


Document Has Been Signed on 08/15/2024 11:17 AM - 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: 334DATE:
08/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mary Shcramm, Administrator of Assisted Living and Memory Support.TIME COMPLETED:
11:25 AM
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At approximately 9:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident follow-up visit regarding a Death Report submitted to CCLD on 8/1/2024 reporting a resident who fell which resulted in death, as well as to clear POCs and follow up on IRs and SOC341's received by CCLD. LPA met with Mary Shcramm, Administrator of Assisted Living and Memory Support. Facility is an Continuing Care Residential Community (CCRC) with 334 residents in care.

At approximately 9:30 AM, LPA reviewed documentation submitted to CCLD by the POC due date 7/31/2024 for POC issued during 7/3/2024 annual inspection. LPA cleared POC and provided Administrator with Letter of Deficiency Citation Cleared.

At approximately 9:35 AM, Kristine Soriano, Resident Service Director was contacted by Administrator to provide copies of the following documentation requested by LPA regarding said Death Report: decedent's care plan, physician's report (LIC602), call response time log for room, and a copy of the death certificate. LPA received copies of said documents except for death certificate which facility has not yet received. Facility to provide death certificate to CCLD upon receipt.

At approximately 10:30 AM, LPA followed up on IR and SOC341 from 6/19/2024 which LPA obtained documentation of during 7/3/2024 annual inspection, regarding a husband and wife allegedly involved in an" argument/physical altercation" on 6/18/2024. There were a few calls to police over a few months regarding husbands declining mental state and altercations between the couple. Facility met with the family and attempted to resolve the situation by moving the couple from independent living to assisted living with a plan to transition the husband into memory care. They decided to move to another facility.

Continued on LIC809D...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie FlorioTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024
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 2


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: 08/15/2024
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...Continued from LIC809

LPA also followed up on SOC341 from 4/8/2024 which LPA obtained documentation of during 7/3/2024 annual inspection, which allegedly involved a dementia resident entering another dementia resident's room and slapping them when asked to leave. Administrator states the alleged abuser did not have a history of this type of behavior and received 1:1 supervision for "a little bit but then moved out" of facility.

No deficiencies were cited during this visit.

Exit interview conducted with Administrator. 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: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC809 (FAS) - (06/04)
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