286803879-12-28-2023-21-AS-HRUS-CYXUJK-20231228143740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803879
Report Date: 12/28/2023
Date Signed: 12/28/2023 02:37:46 PM

Document Has Been Signed on 12/28/2023 02:37 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:	ASSISTED LIVING OF NAPA VALLEY-SHERMAN		FACILITY NUMBER:	286803879
ADMINISTRATOR:	SMITH, KRYSTAL		FACILITY TYPE:	740
ADDRESS:	1460 SHERMAN AVE		TELEPHONE:	(707) 312-2971
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	6	CENSUS: 5	DATE:	12/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Christine Arnke		TIME COMPLETED:	02:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:30AM to conduct an Annual Required inspection and to follow up on an Incident Report that was recieved by Community Care Licensing (CCL) on 12/22/2023. LPA was greeted by Administrator, Christine Arnke. LPA and Administrator discussed the purpose of the visit. LPA and Administrator initiated a walk through of facility at approximately 9:45AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathrooms used by residents measured at 115 and 114 degrees F which are within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Emergency food is rotated and water is stored in the garage along with Personal Protective Equipment. Fire extinguisher was last serviced 10/06/2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection. Most recent fire/disaster drill was conducted 11/26/2023. Five staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Administrator certificate for Administrator, Christine Arnke (6058377740) expired on 08/08/2023 and is on the pending list for renewal. Medications and medication records were reviewed. Continued on LIC809C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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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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: ASSISTED LIVING OF NAPA VALLEY-SHERMAN	FACILITY NUMBER: 286803879
	VISIT DATE: 12/28/2023

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Continued from LIC809

During review of resident records, it was noted that Resident 1 (R1) is bedridden as per their physicians report. Per conversation, R1 is unable to reposition themselves without assistance. LPA is requesting the following documents in order to update the facility fire clearance:
-Updated facility sketch indicating which bedroom will be for bedridden resident
-Updated LIC200 requesting bedridden fire clearance in section 1b (printed and provided to Administrator)

During visit, LPA followed up on Incident Report received by CCL on 12/22/2023. Incident report states that on 12/20/2023 and 12/21/2023, Resident 2 (R2) was aggressive towards staff and made multiple attempts to leave the facility. Staff stayed with resident during all attempts to leave the facility. On 12/20/2023, R2's family and Licensee discussed relocation. On 12/21/2023, R2 attempted to leave the facility and Administrator followed. While outside R2 struck Adminstrator. Law enforcement was contacted as well as R2s family. Family member requested that they take R2 to their home. R2 went to the family members home and Licensee further discussed with family members R2s relocation.

Per conversation with Administrator, R2 was appropriately placed into facility based on R2s physicians report and resident appraisal. R2s Power of Attorney (POA) informed Administrator(s) that R2 has difficulties with their mental health. However, their physicians report revealed no diagnosis' other than their dementia diagnosis. Administrator confirmed that R2's POA was in favor of relocating R2 due to their need for a higher level of care. LPA reviewed R2's physicians report and confirmed that there were no mental health diagnosis' that would reveal R2 needing a higher level of care than what facility could provide.

No deficiencies cited during inspection.

LPA is requesting the following documents to be submitted to CCL by 01/28/2024:
LIC 500 Personnel Report
Liability Insurance
LIC 9020 Resident Roster

Exit interview conducted. Copy of report, LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Helena Rummonds	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC809 (FAS) - (06/04)

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