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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803919
Report Date: 04/18/2024
Date Signed: 04/18/2024 09:20:39 AM


Document Has Been Signed on 04/18/2024 09:20 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: 125DATE:
04/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Grant Wegner, AdministratorTIME COMPLETED:
09:30 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 regarding elopement submitted to Community Care Licensing (CCL).

On 6/28/2023 resident (R1) eloped from facility although R1’s Physician’s Report of January 5, 2023 indicated resident had Mild Cognitive impairment and following incident, resident ‘s reassessment their doctor determined that they were able to leave the facility unassisted. On 10/13/2023 R1 had a change of condition and had a new assessment.

On 4/10/2024 CCL received a self reported incident report from the facility that on 4/9/2024 R1 left the facility unassisted through the front doors and was gone for approximately 45 minutes before staff located, 3 blocks away. LPA obtained current Physician’s Report of February 9, 2024 that indicates resident is not able to leave facility unassisted. Administrator informed facility is providing adequate staffing and working with responsible parties to ensure R1’s needs are met.

LPA is issuing a citation today for R1 eloping from facility without staff knowledge on 4/9/2024.

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: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
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 04/18/2024 09:20 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: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2024
Section Cited
CCR
87411(a)

1
2
3
4
5
6
7
87411(a) Personnel Requirements – General- (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
 /Administrator to provide staff training on residents with 602’s that state are not allowed to leave the facility unassisted due to memory care issues. Training documents to be signed & dated by staff due to CCL by COB 4/18/2024.
Admin has informed R1 has been moved to the memory care section of the facility.
8
9
10
11
12
13
14
Based on LPA record review & interview with Administrator, facility was not competent to provide the services necessary to meet residents need when resident left facility through the front doors alone and had current 602 indicating unable to leave facility unassisted. Which is an immediate health and safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Administrator providing training documents. Citation cleared at today’s 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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2