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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803919
Report Date: 07/18/2023
Date Signed: 07/18/2023 02:26:07 PM


Document Has Been Signed on 07/18/2023 02:26 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:WATERMARK AT NAPA VALLEY, THEFACILITY NUMBER:
286803919
ADMINISTRATOR:GRANT WEGNERFACILITY TYPE:
740
ADDRESS:4055 SOLANO AVENUETELEPHONE:
(707) 345-1480
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:240CENSUS: 111DATE:
07/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Pamela Felisco, Wellness DirectorTIME COMPLETED:
02:35 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct a Case Management inspection and met with Pamela Felisco, Wellness Director. Administrator was unavailable during inspection.

LPA is following up regarding a recent elopement involving resident, R1 who left the facility for approximately a half hour. R1's Physician's Reports signed January 5, 2023 indicated that resident had Mild Cognitive Impairment and did not exhibit wandering behavior but stated they were not able to leave the facility unassisted. Following incident, resident was reassessed and their doctor determined that they are able to leave the facility unassisted.

LPA is also following up regarding a recent incident where a resident reported that money was missing from their wallet. Facility has initiated an investigation. LPA instructed facility staff to file a police report.

No deficiencies cited during this visit.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2023
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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