<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803919
Report Date: 12/12/2023
Date Signed: 12/12/2023 10:04:40 AM


Document Has Been Signed on 12/12/2023 10:04 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: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: 117DATE:
12/12/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Grant WegnerTIME COMPLETED:
10:15 AM
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) Hansen conducted an unannounced case management and met with Administrator, Grant Wegner. The purpose of this case management inspection is to follow up on a self-reported incident report submitted to Community Care Licensing (CCL).

CCL received a self-reported incident report form on 12/04/2023 reporting on 12/01/2023 at approximately 3:00 pm resident (R1) had left locked memory care unit. R1 was observed having agitation & exit seeking at approximately 2:30 pm by facility staff. At approximately 3:30 pm facility staff answered doorbell to back of facility to R1. No visible signs of injury noted and R1 denied any pain. LPA obtained records indicating R1 has diagnosis of dementia and is not to leave unassisted. Interview with Administrator informed R1 exit seeks. LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 12/01/2023.

Appeal of Rights Given.



The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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


Document Has Been Signed on 12/12/2023 10:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: WATERMARK AT NAPA VALLEY, THE
FACILITY NUMBER: 286803919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2023
Section Cited
CCR
87705(b)(2)

1
2
3
4
5
6
7
87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. Not met as evidence by**
1
2
3
4
5
6
7
Facility provided in-service training conducted with Memory Care, for regulation 87705 Care of Persons with Dementia with staff. And will have additional training on 12/12/2023 with Housekeeping & kitchen teams. Obtained copy of trainings w signatures and dates.
8
9
10
11
12
13
14
Based on record review and interview with Administrator, it was found that resident (R1) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.
8
9
10
11
12
13
14
 Facility back door will no longer be used as a shortcut to the dumpster & cameras have been installed on the exterior of the bldg. doors.

. Citation cleared at visit ******

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2