286803919-8-13-2024-21-AS-ALOA-D84UKM-20240813153922

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 286803919
Report Date: 08/13/2024
Date Signed: 08/13/2024 03:39:38 PM

Document Has Been Signed on 08/13/2024 03:39 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, THE		FACILITY NUMBER:	286803919
ADMINISTRATOR:	GRANT WEGNER		FACILITY TYPE:	740
ADDRESS:	4055 SOLANO AVENUE		TELEPHONE:	(707) 345-1480
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	240	CENSUS: 117	DATE:	08/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Grant Wegner - Executive Director		TIME COMPLETED:	03:55 PM

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Licensing Program Analyst (LPA’s) Tony Loera and Chris Arnhold arrived unannounced to conduct a required Annual inspection and were greeted by Executive Director Grant Wegner. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently one hundred and seventeen(117) residents in care. Facility approved/cleared for 91 ambulatory, 129 non-ambulatory, and 20 bedridden.

At approximately 9:20 am, LPA’s and Executive Director toured the building and grounds. The facility was found to be at a comfortable temperature. LPA’s observed a 2 day supply of perishable and 7 day supply of non-perishable food. All food was found to be stored in a safe manner being labeled and dated.
Medications were found to be centrally stored and secured. All rooms were equipped with lighting, night stand, and chest of drawers. All rooms were in good repair. Extra hygiene products and linens were available. Water temperature at faucets accessible to residents in care were measured within the range of 105 to 120 degrees F.

Fire extinguishers were last inspected July 23, 2024. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility has fire sprinklers throughout.

At approximately 11:15 am, LPA’s conducted a review of 15 resident records. All records had the required documentation. All care plans and physician reports were up to date.

At approximately 1:30 pm, LPA’s conducted review of (ten) 10 staff records. Five of ten staff records did not contain documentation of required training. Facility is currently undergoing a transfer in how they conduct and document training. LPA’s and Executive Director discussed facility's training plan/method for better
documentation.

Continued on LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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: WATERMARK AT NAPA VALLEY, THE	FACILITY NUMBER: 286803919
	VISIT DATE: 08/13/2024

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC308- Designation of Responsibility
LIC309- Administrative Organization
Liability Insurance
Current Lease Agreement

Exit interview conducted with Administrator and a copy of this report was given.

No citations issued during this visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC809 (FAS) - (06/04)

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