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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803919
Report Date: 07/25/2022
Date Signed: 07/25/2022 02:50:26 PM


Document Has Been Signed on 07/25/2022 02:50 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:WATERMARK AT NAPA VALLEY, THEFACILITY NUMBER:
286803919
ADMINISTRATOR:HARRELL, YOLANDAFACILITY TYPE:
740
ADDRESS:4055 SOLANO AVENUETELEPHONE:
(707) 345-1480
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:240CENSUS: 78DATE:
07/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator, Yolanda HarrellTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a Case Management Inspection at approximately 1:45 PM on 07/25/2022. LPA met with administrator, Yolanda Harrell. This inspection is a follow up to an incident report received by Community Care Licensing on 07/19/2022.

On 07/13/2022, Resident 1 (R1) exited the memory care unit at approximately 6:40 PM through a delayed egress door visible from R1's door. Door requires a FOB to exit, once door is opened and closed with FOB there is a 15 second window where the door is still able to be pushed open. This door opens into a stair well. At the far end of the stair well is a door which opens to the parking lot. R1 exited through this final door and walked a block down to the fire department. R1 was out for approximately 20 minutes.

Administrator had staff perform an elopement drill/training on 07/14/2022. Updates have been made to R1's care plan and adjustments have been made to R1's medication. Facility is working with maintenance on adding delayed egress to the stairwell door as well as cameras.

LPA received copies of resident records and staff training.

No deficiencies cited during today's inspection. Exit interview conducted with administrator and a copy of the report printed for the facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022
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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