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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803919
Report Date: 08/30/2021
Date Signed: 08/30/2021 11:11:50 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2021 and conducted by Evaluator Angela Elliott
COMPLAINT CONTROL NUMBER: 21-AS-20210323113445
FACILITY NAME:WATERMARK AT NAPA VALLEY, THEFACILITY NUMBER:
286803919
ADMINISTRATOR:ORDING, KELLYFACILITY TYPE:
740
ADDRESS:4055 SOLANO AVENUETELEPHONE:
(707) 345-1480
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:240CENSUS: 51DATE:
08/30/2021
UNANNOUNCEDTIME BEGAN:
10:30 PM
MET WITH:Chad RogersTIME COMPLETED:
11:15 PM
ALLEGATION(S):
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Facility does not have a qualified Administrator
Facility staff are not properly trained
Facility staff do not respond to residents call button in a timely manner
Staffing is not adequate to meet resident's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott arrived unannounced to deliver findings for the complaint allegations listed above. LPA met with Chad Rogers, Executive Director.

There is an allegation facility does not have a qualified Administrator. According to AccuShield Documentation, between 1/1/2021 and 4/1/2021 S1, the designated Administrator was on site at the facility once. Personnel Report received on 3/30/2021 does not reflect a staff designated as Administrator. Per interview on 7/27/2021 S1 does not have a set schedule at the facility. Interview with S1 on 7/27/2021 indicated the facility couldn’t get S3 through their Administrator training before they left in June 2021. E-mail from S1 on 8/11/2021 indicates facility is not ready to add a new Administrator. Performance expectations description for an Executive Director/Administrator reflects must be certified as an Administrator under Specific Requirements. Based on LPA’s observations, interviews conducted and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

See 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 21-AS-20210323113445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: WATERMARK AT NAPA VALLEY, THE
FACILITY NUMBER: 286803919
VISIT DATE: 08/30/2021
NARRATIVE
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There is an allegation facility staff are not properly trained. LPA reviewed training records for four staff. Three out of four training records did not meet regulatory requirements. E-mail from S2 on 4/7/2021 discussed training may have taken place elsewhere, but there was no documentation to support it. Interviews held on 6/29/2021 revealed that staff lack training. Based on LPA observation, interview and record review, staff did not have required training hours. Based on LPA’s observations, interviews and a review of records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

There is an allegation facility staff do not respond to resident’s call button in a timely manner. Skynet report from 12/1/2020-3/29/2021 reflect at least two hundred and eighty-two response times between 10-30 minutes, at least 66 response times between 30-60 minutes, and at least nineteen response times that were more than 60 minutes. LPA’s interviews with reisdents and staff confirm delayed response times for residents. Based on LPA’s observations, interviews conducted and a review of records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

There is an allegation staffing is not adequate to meet resident's needs. Staffing schedules from December 2020-April 2021 reveal staffing level of 1-2 staff on AM, PM’s and NOC’s. On 5/31/2021 R1 wandered away from the facility. R1’s Physician’s Report dated 7/8/2020 reflects R1 is not able to leave the facility unassisted. Interviews with residents on 6/29/2021 and with staff on 8/26/2021 confirm staffing was not adequate to meet resident’s needs. Based on LPA’s observations, interviews conducted and a review of records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. 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: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20210323113445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WATERMARK AT NAPA VALLEY, THE
FACILITY NUMBER: 286803919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2021
Section Cited
CCR
87411(a)
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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:
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Licensee to ensure sufficient staffing to meet the needs of residents. Licensee agrees to submit updated staffing schedule, showing 24-hour coverage to meet the needs of residents. Updated staffing schedule to be submitted to CCL by COB 8/31/2021.
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Based on LPA observation, interview and record review facility has delayed call response for residents using their pendants. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.
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Type A
08/31/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements-General (a) Facility Personnel shall at all times be sufficient in number, and competent to provide the services necessary to meet resident needs. This requirement was no met as evidenced by:
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Licensee to ensure staff are sufficient in numbers to meet the needs of residents. Licensee agrees to submit staffing schedule showing 24 hours coverage to meet the needs of the residents. Updated staffing schedule to be submitted to LPA by POC date of 8/31/2021.
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Based on LPA observation, interview and record review, facility did not provide supervision resulting in R1 leaving the facility. This is an immediate risk to the Health, Safety and Rights of residents in care.
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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: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 21-AS-20210323113445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: WATERMARK AT NAPA VALLEY, THE
FACILITY NUMBER: 286803919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
87415
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87405 Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator...and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This requirement was not met as evidenced by:
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Licensee to ensure qualified Administrator is on the premises. Licensee agrees to send LPA schedule reflecting designated Administrator on the premises a sufficient number of hours by COB 9/13/2021.

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Based on LPA observation, interview and record review, a qualified Administrator was not on the premises. This is a potential risk to the Health, safety and personal rights of the residents in care.

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Type B
08/31/2021
Section Cited
HSC
1569.625
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1569.625 Staff training; legislative findings; contents: (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly...This training shall consist of 40 hours of training.
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Licensee to ensure staff have current training. Licensee agrees to develop a written plan to ensure staff receive the required training. Plan to be submitted to LPA by POC date of 9/13/2021.

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This requirement is not met as evidenced by: Based on records review, Licensee did not provide staff the required number of training hours. This poses a potential risk to the health, safety and personal rights of residents in care.
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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: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2021 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210323113445

FACILITY NAME:WATERMARK AT NAPA VALLEY, THEFACILITY NUMBER:
286803919
ADMINISTRATOR:ORDING, KELLYFACILITY TYPE:
740
ADDRESS:4055 SOLANO AVENUETELEPHONE:
(707) 345-1480
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:240CENSUS: 51DATE:
08/30/2021
UNANNOUNCEDTIME BEGAN:
10:30 PM
MET WITH:Chad RogersTIME COMPLETED:
11:15 PM
ALLEGATION(S):
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Facility is not following admissions agreement
Facility staff does not allow residents to have visitations in their room
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott arrived unannounced to deliver findings for complaint allegations listed above. LPA met with Chad Rogers, Executive Director.

There is an allegation facility is not following admissions agreement. LPA interviewed facility Executive Director on and residents on 6/29/2021. LPA reviewed resident records dating back to May 2018. Based on the records reviewed an interviews there is no evidence to support the facility was not following admission agreement. The allegation is UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

There is an allegation facility staff does not allow residents to have visitations in their room. . Resident interview on 6/29/2021 reflected visitations in room were taking place. PIN 20-38 dated 10/6/2020 reflects, best practices for visitation indicated indoor visits should be in a designated area that is near an entrance and exit if it helps ensure safety.

See Lic 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20210323113445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: WATERMARK AT NAPA VALLEY, THE
FACILITY NUMBER: 286803919
VISIT DATE: 08/30/2021
NARRATIVE
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other residents are not exposed to visitor. Interview with S3 on 3/25/2021 reflected no in room visit were allowed unless somebody was moving in, then families could go into their rooms for assistance.
Although reporting party alleges select families were given permission to visit in resident apartments, there was no additional information that was able to be obtained to support the allegation. The allegation is UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2021 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210323113445

FACILITY NAME:WATERMARK AT NAPA VALLEY, THEFACILITY NUMBER:
286803919
ADMINISTRATOR:ORDING, KELLYFACILITY TYPE:
740
ADDRESS:4055 SOLANO AVENUETELEPHONE:
(707) 345-1480
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:240CENSUS: 51DATE:
08/30/2021
UNANNOUNCEDTIME BEGAN:
10:30 PM
MET WITH:Chad RogersTIME COMPLETED:
11:15 PM
ALLEGATION(S):
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Facility staff does not have necessary forms posted at the facility
INVESTIGATION FINDINGS:
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There is an allegation facility does not have necessary forms posted at the facility. LPA conducted tele visit on 1/5/2021 and observed required postings at the facility. Outside party confirmed they observed required postings at the facility in March 2021. Based on LPA observation, and interview, it has been determined the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 7