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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803919
Report Date: 09/09/2022
Date Signed: 09/09/2022 03:30:20 PM


Document Has Been Signed on 09/09/2022 03:30 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: 83DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Associate Executive Director, Grant WegnerTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/09/2022 to conduct a Required - 1 Year inspection. LPA met with Associate Executive Director, Grant Wegner. This inspection was focused on the infection control procedures and practices of this facility.

Facility is a three story facility with independent living, assisted living, and memory care. LPA toured building and grounds which were found to be clean and in good repair. Exits and walkways were free from obstructions. Visitors are screened at the front entrance with an Accushield device. Facility has a common dining area for IL and AL on the first floor. Toxins are kept locked and secured. Medications are kept locked and secured in resident bedrooms. MedTechs assist residents with medications daily. High touch surface areas are disinfected daily. Staff have been N95 fit tested and provided with infection control training. Director and LPA discussed incident report submitted to Community Care Licensing about incident which occurred on 08/27/2022.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
LIC610E- Disaster Plan
Evidence of Liability Insurance

Exit interview conducted with Associate Executive Director, Grant Wegner and a copy of this report was printed for the facility.

No deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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