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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803675
Report Date: 06/24/2021
Date Signed: 06/25/2021 08:53:57 AM

Document Has Been Signed on 06/25/2021 08:53 AM - 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ASSISTED LIVING OF NAPA VALLEY-HAMILTONFACILITY NUMBER:
286803675
ADMINISTRATOR:SMITH, KRYSTALFACILITY TYPE:
740
ADDRESS:3100 HAMILTON STREETTELEPHONE:
(707) 637-4562
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY: 9CENSUS: 6DATE:
06/24/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Chrissy Arnke/Krystal SmithTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) obtained information during complaint Investigation 21-AS-20210623113620 regarding facility process with R1 and Coumadin clinic. Facility did not keep record of weekly dosage of Coumadin given to R1. LPA was also sent Special Incident Report for an incident on 10/15/2021 pertaining to R1 on 6/11/2021. LPA reviewed findings with Chrissy Arnke, Administrator and Krystal Smith, Licensee via Face Time.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Licensee.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 06/25/2021 08:53 AM - It Cannot Be Edited


Created By: Angela Elliott On 06/24/2021 at 08:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: ASSISTED LIVING OF NAPA VALLEY-HAMILTON
FACILITY NUMBER: 286803675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/24/2021
Section Cited
CCR
87465(a)(7)

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87465 (a)(7) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. (7) When requested ... a record of dosages of medications which are centrally stored shall be maintained. Based on LPA observation/interview/record review this requirement was not met as evidenced by:

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Licensee to ensure dosages of medication are documented. Licensee agrees to submit a plan to ensure documentation of each dose of prescribed/non prescribed including PRN medication to CCL by POC due date of 6/25/2021.
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Community Care Licensing (CCL) requested documentation related to R1's medication, specific dosages of medication were not documented. This is an immediate risk to the Health, Safety and Personal Rights of residents in care.

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Type B
06/24/2021
Section Cited
CCR87211

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87211 Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when a resident incurs any serious injury while under facility supervision or death. This requirement is not met as evidenced by:
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Licensee to ensure all incidents are reported to CCL per regulation. Licensee agrees to review regulation and conduct training for all staff on reporting requirements. Licensee agrees to send training roster to CCL by POC date of 7/8/2021.
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Based on LPA’s records review and interviews conducted Licensee did not ensure that CCL was notified when R1 was taken to the emergency room and admitted into the hospital which poses a potential 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:Bethany Moellers
LICENSING EVALUATOR NAME:Angela Elliott
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021


LIC809 (FAS) - (06/04)
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