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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286801070
Report Date: 07/03/2023
Date Signed: 07/03/2023 11:32:40 AM


Document Has Been Signed on 07/03/2023 11:32 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
CCLD Regional Office, 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: 310DATE:
07/03/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary SchrammTIME COMPLETED:
11:45 AM
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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to complete the annual inspection that began on 06/22/2023. LPA met with Administrator Mary Schramm and reviewed records and discussed the emergency disaster plan.
At approximately 9:30AM, LPA reviewed 10 of 52 resident records. 10 of 10 contained current assessments, Physician reports and signed admission agreements.
At approximately 10:50AM, LPA reviewed 10 of 36 staff records. LPA observed 10 of 10 records contained documentation of completed required annual training and current First Aid/CPR certification.
At approximately 11:15AM, LPA reviewed the facility emergency disaster plan. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has the required evacuation stair chairs in place. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 1/11/2023 and a fire drill on 06/27/2023.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
Verification of control of property
LIC500- Personnel Report
Evidence of Liability Insurance

No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2023
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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