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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803919
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:46:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20220928124152
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: 81DATE:
10/06/2022
UNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Administrator, Grant WegnerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst Erik Gonzalez Campos arrived unannounced on 10/06/2022 to conduct a complaint inspection regarding the allegation that staff hit a resident. LPA met with administrator Grant Wegner.

During the inspection LPA conducted interviews and reviewed records. On 09/27/2022 the Santa Rosa regional office received an incident report regarding an incident in which Staff 1 (S1) slapped a resident on 09/20/2022. In response S1 was terminated, and the facility conducted training on abuse/reporting requirements for staff members. During the inspection LPA interviewed staff present at the time of incident who confirmed that caregiver had slapped resident.

Based on record review and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal rights given
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
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 2
Control Number 21-AS-20220928124152
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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, THE
FACILITY NUMBER: 286803919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation intimidation, abuse, or other actions of a punitive nature. This requirement was not met as evidenced by:
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Facility has terminated S1 and conducted abuse/reporting training for caregivers.

Deficiency cleared during the inspection on 10/06/2022 and facility provided with clearance letter.
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On 09/20/2022 staff 1 (S1) slapped resident 1 (R1) which poses an immediate health and safety risk to 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2