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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801070
Report Date: 07/13/2021
Date Signed: 07/13/2021 03:59:45 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: 41DATE:
07/13/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Dorene WarchutTIME COMPLETED:
02:00 PM
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At 1:25 PM Licensing Program Analyst (LPA) Angela Elliott and LPA Shannan Hansen arrived unannounced to conduct case management visits for a series of incidents at the facility. LPAs met with Dorene Warchut Resident Services Coordinator.

On 6/7/2021 R1 was discovered on the floor of their dining room. 911 was called and R1 was assessed at Queen of the Valley Hospital and diagnosed with a fractured left should and right knee. Currently R1 is at the Skilled Nursing portion of the facility for physical therapy and occupational therapy and has been added to the falls committee. It is expected they will return to the facility after treatment.

On 6/30/2021 R2 was having episodes of spitting up phlegm and yellow substance. R2 was also complaining of chest pain, was sent out to Queen of the Valley Hospital and returned to facility on 7/1/2021. On 7/2/2021 R2 asked for staff assistance to the bathroom three times. R2 appeared to be having a seizure at one point was having chest pain and indicated they felt weak. R2 was sent to Queen of the Valley and was diagnosed with Norovirus. R2 came back to the facility on the 7/4/2021 and was isolated. Facility ceased communal dining and activities during this time and they were restarted on 7/7/2021. There have been no further cases diagnosed at the facility.

On 7/8/2021 R3 was having difficulty breathing, 911 was called and R3 was diagnosed with Dyspnea and Apneic episode. X-ray noted some opacities possibly due to aspiration. R3 has been assessed with speech evaluations to determine the appropriate diet. R3 and family does not consent to recommended texture of diet. Treatment meeting was recently held and it was determined to leave current diet in place with acknowledged risks. Current diet is regular.

LPAs requested documentation. No citations issued during today's visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2021
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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