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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803919
Report Date: 11/16/2021
Date Signed: 11/16/2021 01:09:36 PM



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
09/29/2021 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210929093601
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: DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Grant WegnerTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Facility did not follow evacuation plan

Resident dietary restrictions not followed
INVESTIGATION FINDINGS:
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to deliver findings for the above allegations. LPA met with Associate Director, toured facility and reviewed records. At approximately 9:40AM, LPA interviewed Safety Director Bryce Groth and received a copy of emergency disaster plan. When a fire alarm sounds at the facility, residents shelter in place while staff locate the source of the alarm. After the event, staff are to account for each resident, visitor and staff. Facility staff did not make contact with each resident after an alarm on 08/12/2021, causing residents to stay in their rooms for an extended period of time. Facility is updating their disaster response procedures to ensure the safety and well-being of residents. At approximately 10:30AM, LPA interviewed staff and reviewed documentation concerning resident food and drug allergies. Resident had food and drug allergies listed on their physician report when moving into the facility in October 2020... Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 4
Control Number 21-AS-20210929093601
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: 11/16/2021
NARRATIVE
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but the information was not entered into the dietary system until July 2021. An updated physician report has been completed that addresses their food and drug allergies, and the information has been entered into the resident care system.

Based on the Departments investigation, 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.


This report was reviewed with Grant Wegner and Appeal rights were given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
09/29/2021 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210929093601

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: DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Grant WegnerTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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Emergency call system not operating

Facility is short staffed to cover planned activities
INVESTIGATION FINDINGS:
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At approximately 8:45AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to deliver findings for the above allegation. LPA met with Associate Director Grant Wegner, toured facility and reviewed records. Facility has a wireless resident call system throughout the facility and has not had an outage since the installation. LPA was informed there were a few areas in the facility where it became known the signal strength was weak. Facility contacted the call system company, who came and corrected the signal strength. LPA reviewed staffing records and activity schedules. Facility has assigned staff for activities but if a staff were to test positive for Covid-19, they would not be permitted to conduct the activity.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20210929093601
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: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/15/2021
Section Cited
CCR
87458(a)
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87458 Medical Assessment:...the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This standard is not met as evidenced by
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Licensee has changed procedures during resident intake to ensure dietary and allergy information is communicated to various departments. POC Cleared during visit.
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Based on record review, Licensee did not ensure dietary restrictions were followed as listed on Physician report. This poses a potential Health and Safety risk to residents in care.
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Type B
12/15/2021
Section Cited
CCR
87212(b)(2)(F)
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87212 Emergency Disaster Plan: Supervision of residents during evacuation or relocation and contact after relocation to assure that relocation has been completed as planned. This requirement is not
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Licensee to ensure staff are trained and understand the emergency disaster plan. Licensee to conduct training with all staff on their role in an emergency. Licensee to submit staff attendance roster of completed
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met as evidence by: Based on record review and interviews conducted, Licensee did not ensure residents were contacted after event. This poses a potential Health or Safety risk to residents.
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training to CCL by POC date of 12/15/2021.
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) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4