The Meadows of Napa Valley

Type of visit: Required - 1 Year

At approximately 3:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Alisha Vinson, Administrator. Facility is an Continuing Care Residential Community (CCRC) with residents in care, 50 of whom reside in the assisted living and memory care units. Community has a Hospice waiver for 15. LPA obtained a copy of the resident roster, facility census, and staff roster. LPA will return at a later date to complete this annual inspection. No Deficiencies are being cited during inspection. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 7, 2026

Allegation investigated: Neglect resulted in resident sustaining an injury causing death

On 01/30/2026, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20251024124228 investigation findings and met with Kristine Morrow, Executive Director. Reporting Party (RP) alleges neglect resulted in resident sustaining an injury causing death. LPA Florio conducted 10-day complaint investigation visit on 10/27/2025 and obtained documents. Resident 1 (R1) experienced a witnessed fall on 10/16/2025. Facility staff were unable to prevent R1 from falling and appropriately activated Emergency Medical Services (EMS). R1 denied being in pain and initially refused to be treated at the hospital when Emergency Medical Responders (EMR) evaluated them. R1 was transported to the hospital; they passed away on 10/17/2025. A local Coroner’s Office conducted an investigation and determined that R1’s immediate cause of death was brain death, intracranial hemorrhage, and traumatic injury of head as a result of an accidental ground level fall. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding the above allegation. Based on interviews conducted, observations made, and records obtained, the allegation that neglect resulted in resident sustaining an injury causing death is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Executive Director, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 21-AS-20251024124228

Allegation investigated: Staff are not following reporting requirements

***AMENDED DOCUMENT DUE TO REPORT INDICATING WRONG FINDING*** On 01/30/2026, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20251024124228 investigation findings and met with Kristine Morrow, Executive Director. Reporting Party (RP) alleges staff are not following reporting requirements. LPA conducted 10-day complaint investigation visit on 10/27/2025 and obtained documents. Per an Unusual Incident/Injury Report received by the Department on 10/21/2025, on 10/16/2025, Resident 1 (R1) sustained a fall that resulted in the activation Emergency Medical Services (EMS). R1's Admissions Agreement dated 08/27/2024, Emergency Identification form dated 08/20/2024, Advanced Health Care Directive (AHCD) dated 05/09/2023, and Health Information Portablity and Accountability Act (HIPAA) form dated 05/03/2023, are all signed by R1 and name R1's son as the responsible party/agent/respesentative. Both R1's AHCD and the HIPAA state they are effective immediately upon their execution. On 01/30/2026, LPA obtained additional documents and conducted an interview with Executive Director where it was revealed that R1's responsible party was notified via telephone/text message only intially. A written report was not provided to the responsible party until 11/14/2025 along with copies of the rest of R1's records. Per California Code of Regulation (CCR) section 87211(a)(1)(B), "A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. [...] Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision." It was discused with Executive DIrector that per CCR section 87101(r)(6) "Responsible Person" means "Representative," as defined in Section 87101(r)(3), for purposes of these regulations and applicable statutes. Further, per CCR 87101(r)(3) "Representative" means an individual who has authority to act on behalf of the resident; including but not limited to, a conservator, guardian, person authorized as the agent in the resident’s valid advance health care directive, the resident’s spouse, registered domestic partner, family member, a person designated by the resident, or other surrogate decisionmaker designated consistent with statutory and case law [...]. Continued on LIC9099C... Substantiated Continued from LIC9099... Based on observations made, interviews conducted and records obtained, the allegation staff are not following reporting requirements is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Executive Director, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 30, 2026 · control 21-AS-20251024124228

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 27, 2026

Reporting Requirements 87211(a)(1): A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence [....]. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, Licensee did not ensure that R1's responsible party received a written report of the incident that occurred on 10/16/2025 within seven days of the occurence which poses a Health, Safety and/or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 30, 2026

Plan of correction: Licensee shall self certify that they will ensure that the required written reports are submitted to all the required parties within the required seven day reporting timeframe to CCLD by POC due date 02/27/2026.

Type of visit: Case Management - Incident

Licensing Program Analysts (LPAs) Julie Florio and Marisol Cuadra arrived unannounced to conduct a case management - incident inspection and met with Kristine Morrow, Administrator, Tracy Ferreira, Residents Service Coordinator and Justin Zackzewsky, Residents Services Director. LPAs are conducting a case management visit to obtain more information regarding an incident report received by the Department on 1/8/26 for an incident about car theft which occurred on 12/22/2025. LPAs have a conversation with Administrator regarding reporting requirements of notifying the Department within seven days of occurrence. According to incident report, on 12/22/25 at approximately 12:30pm, resident (R1) reported to staff that their car was missing. Per R1, they noticed the car was gone from their designated parking spot when they were attempting to go to a doctor's appointment that day. R1 stated that the car was locked and that no one else has access to the vehicle, R1 filed a police report - case# NPD-254952. During today's visit, LPAs learned that the facility is actively working with the Napa Police Department to help residents by re-educating them and conducting a presentation on 2/17/26, as well as transportation and parking committee connection with police. LPAs reviewed R1's records, conducted interviews and obtained pertinent documentation including internal investigation conducted on 12/22/25. Per investigation report, the theft of the vehicle recorded by surveillance camera ISMS system occurred on 12/21/25 at 9:22pm describing the following: "white car (unknown license plates) is seen on camera parked behind spot B4, one individual seen in car, starts car and both car leave. No staff or residents caught on camera. Cameras don't capture the entire incident just the start of the car and drive off". Based on records review and interviews with facility staff, the facility followed all regulation and training requirements protocols. LPAs will review documentation received to determine if further action is needed. No deficiencies were cited during todays visit. Exit interview was conducted with Administrator, and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 21, 2026

Type of visit: Case Management - Incident

On 11/13/2025, at approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident inspection and met with Kristine Morrow, Administrator. LPA is conducting a case management visit to obtain more information regarding two incident reports received by the Department: (1) the first received by the Department on 11/7/2025 for an incident which occurred on 10/28/2025; and (2) the second received by the Department on 11/04/2025 for an incident which occurred on 10/31/2025. LPA conducted interviews and obtained documents. No deficiencies were cited during todays visit. Exit interview was conducted with Administrator, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Nov 13, 2025

Allegation investigated: Staff did not respond to residents call light in a timely manner.

On 10/07/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250729143855 investigation findings regarding the above allegation and met with Fe Au, Assisted Living Nurse Manager. Reporting Party (RP) alleges that Staff 1 (S1) did not respond to residents call light in a timely manner. LPA Florio conducted 10-day complaint investigation visit on 07/31/2025 and obtained documents, made observations, and conducted interviews. LPA conducted subsequent follow up visits on 09/29/2025 and 10/7/2025 where LPA obtained additional documents and conducted further interviews. It was revealed through review of S1's daily resident assignments and corresponding call light logs for six (6) shifts S1 worked between 07/14/2025 and 07/23/2025 that S1 responded to resident call lights in a timely manner with call light reset times averaging less than four (4) minutes. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding this allegation. Based on interviews conducted and records obtained, the allegation that staff did not respond to residents call light in a timely manner is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Assisted Living Nurse Manager, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Oct 7, 2025 · control 21-AS-20250729143855

Type of visit: Case Management - Incident

On 10/07/2025, at approximately 4:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Kristine Morrow, Administrator. LPA is conducting a case management visit to obtain more information regarding an incident report received by the Department on 08/11/2025 for an incident that occurred on 07/31/2025, involving Resident 1 (R1). LPA conducted an interview and obtained documents. No deficiencies were cited during todays visit. Exit interview was conducted with Administrator, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Case Management - Annual Continuation

At approximately 10:40AM, Licensing Program Analysts (LPAs) Marisol Cuadra and Julie Florio arrived at this facility unannounced, to conduct a subsequent annual inspection that began on 06/11/2025 and met with Administrator Kristi Morrow to review records. At approximately 11:00AM, LPAs reviewed eight resident records and seven staff records. 8 out of 8 resident's records have current medical assessments and care plans. 7 out of 7 staff records have current required annual training and current First Aid/CPR certification. Medication and medication records were reviewed, LPAs observed that start dates for medications not listed on Centrally Stored Medication Record, LPAs have a conversation with nurse manager and the facility agreed to ensure they remain in compliance moving forward (technical violation issued). During today's visit, LPAs are following up on an incident report dated 7/10/25. Per incident report, on 7/8/25 a concerned outside party of resident (R1) contacted the facility regarding several alleged recent large transactions (unknown amounts) from R1's banking account. Facility staff followed up with R1 regarding concerns raised and R1 stated that there was no cause of concern because it was their money and they would spend it as they wanted, which according to R1 it was previously discussed with concerned party. R1 noted that they hired a private caregiver (I1) to get help with shopping. Continue on LIC809C... Continued from LIC809... The facility also contacted R1's responsible party (POA) who indicated that they do have concerns on their own but had "no proof of wrongdoing". R1 will have a conversation with concerned party again regarding their financial decisions. LPAs reviewed resident's records including their physician report dated 5/11/25 and care plan dated 5/13/25 confirmed that R1 is able to manage own cash resources. POA agreement does not indicate that R1's representative have any power over resident's financial decisions. Per conversation with Licensing Program Manager (LPM), LPAs requested the facility submit a report of alleged financial abuse to all required agencies. LPAs requested additional documentation from facility and will follow return to Regional Office and discuss with LPM further. No Deficiencies are cited during this subsequent inspection. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 18, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 12:55 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management visit to follow up on a SOC341 report of suspected dependent adult/elder abuse received by the department on 06/06/2025 and a required 1-year annual inspection and met with Kristi Morrow, Administrator. Facility is an Continuing Care Residential Community (CCRC) with 340 residents in care, 58 of whom reside in the assisted living and memory care units. Community has a Hospice waiver for 15. At approximately 1:10 PM, LPA conducted a follow-up interview with Administrator regarding a SOC341 report of suspected dependent adult/elder abuse received by the department on 06/06/2025 reporting incidences of an intruder in the community who over the course of two days interacted with at least 10 residents in both the independent living and assisted living units of the community. Administrator states the individual was unable to provide a business card and was asked to leave the premises. Allegedly the individual was going door-to-door representing themselves as a registered nurse working with a brain health organization offering cognitive assessments to residents and was collecting personal information from residents, such as insurance and driver's license information and possibly a social security number from one. The local ombudsman and Napa Police Department were notified and LPA obtained an event number from Administrator. To date there have been no reports of any account activity or financial harm to any of the affected residents. Facility is currently working on access, process, and security improvements to prevent any such incidence from occurring in the future. Continued on LIC809-C... Continued from LIC809... At approximately 2:00PM, LPA initiated a tour of the memory care, assisted living and independent living units in the community with Administrator and observed the following: Facility has two- and a three story wings, with evacuation chairs placed at the top of each stairwell. Facility was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. Closets containing cleaning supplies and other items that could pose a risk were locked. The community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply in each building. Medications were centrally stored and locked. There are several covered seating areas and outdoor space for activities throughout the community. LPA observed an activity schedule and computers with internet available for resident use. The community's fire extinguishers were observed charged and were last serviced 01/2025. Sprinklers and Smoke and Carbon Monoxide detectors were last inspected by the a third party fire and security company 05/2025. Facility conducts monthly emergency/disaster drills with the last one conducted 05/2025. LPA observed facility's infection control plan and emergency disaster plan which was last updated 06/2025. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community. Facility has at least three backup generators for emergency preparedness. LPA will return at a later date to conduct file review, inspect medications, and complete this annual inspection. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report (updated) A copy of the property deed - proof of ownership No Deficiencies are cited during inspection. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jun 11, 2025

Type of visit: Case Management - Incident

At approximately 9:15 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a Case Management - Incident follow-up visit regarding a Death Report submitted to CCLD on 8/1/2024 reporting a resident who fell which resulted in death, as well as to clear POCs and follow up on IRs and SOC341's received by CCLD. LPA met with Mary Shcramm, Administrator of Assisted Living and Memory Support. Facility is an Continuing Care Residential Community (CCRC) with 334 residents in care. At approximately 9:30 AM, LPA reviewed documentation submitted to CCLD by the POC due date 7/31/2024 for POC issued during 7/3/2024 annual inspection. LPA cleared POC and provided Administrator with Letter of Deficiency Citation Cleared. At approximately 9:35 AM, Kristine Soriano, Resident Service Director was contacted by Administrator to provide copies of the following documentation requested by LPA regarding said Death Report: decedent's care plan, physician's report (LIC602), call response time log for room, and a copy of the death certificate. LPA received copies of said documents except for death certificate which facility has not yet received. Facility to provide death certificate to CCLD upon receipt. At approximately 10:30 AM, LPA followed up on IR and SOC341 from 6/19/2024 which LPA obtained documentation of during 7/3/2024 annual inspection, regarding a husband and wife allegedly involved in an" argument/physical altercation" on 6/18/2024. There were a few calls to police over a few months regarding husbands declining mental state and altercations between the couple. Facility met with the family and attempted to resolve the situation by moving the couple from independent living to assisted living with a plan to transition the husband into memory care. They decided to move to another facility. Continued on LIC809D... ...Continued from LIC809 LPA also followed up on SOC341 from 4/8/2024 which LPA obtained documentation of during 7/3/2024 annual inspection, which allegedly involved a dementia resident entering another dementia resident's room and slapping them when asked to leave. Administrator states the alleged abuser did not have a history of this type of behavior and received 1:1 supervision for "a little bit but then moved out" of facility. No deficiencies were cited during this visit. Exit interview conducted with Administrator. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Aug 15, 2024

Type of visit: Required - 1 Year

At approximately 8:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection. Kristine Soriano, Resident Services and Independent Living Director was contacted and arrived at approximately 8:50 AM. Facility is an Continuing Care Residential Community (CCRC) with 328 residents in care. Community has a Hospice waiver for 15 with 4 residents currently receiving Hospice services. At approximately 9:10 AM, LPA initiated a tour of independent living facility with Director and observed the following: Facility has a two- and a three-story wing, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. At approximately 10:15 AM, LPA initiated tour of the assisted living and memory care facility with Mary Shcramm, Administrator of Assited LIving and Memory Support. The Assisted living wing is a two stories and memory care in one story. The facility was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. Cabinets containing cleaning supplies and other items that could pose a risk were locked. The community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a covered patio, seating area and outdoor space for activities. LPA observed an activity schedule and a facility computers and internet available for resident use. LPA reviewed medications and medication records which are maintained in compliance with regulation. Continued on LIC809-C... Continued from LIC809... The community's fire extinguishers were observed charged and were last serviced January 2024. Smoke and Carbon Monoxide detectors were observed during inspection. Facility conducts regular bi-annual emergency/disaster drills, and LPA informed Director and staff that these shall be completed quarterly moving forward per regulation. The community's most recent drill was conducted June 2024. LPA observed facility's infection control plan and emergency disaster plan which was last updated April 2016. LPA observed a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community. Facility has a three backup generators. At approximately 1:30 PM, LPA reviewed ten (10) staff files and ten (10) resident files. Ten (10) of ten (10) staff files reviewed has the required current First Aid certificate and each has a current CPR certification as well. Each staff file reviewed had all the required paperwork per regulation. Four (4) of ten (10) resident files reviewed were missing the required updated annual physicians report and updated and signed reappraisal and care needs plan. LPA issued a citation for this (see LIC 809D). LPA observed all the remaining required paperwork in all ten (10) resident files reviewed. Administrator informed LPA that community coordinates medical and dental visits for the majority of their residents. LPA also obtained documents regarding recent IRs and SOC341 during inspection and will follow up with community at a later date. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC610- Emergency Disaster Plan A copy of community Liability Insurance A copy of the property deed - proof of ownership 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. Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jul 3, 2024

Type of visit: Case Management - Incident

At approximately 1:50PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection on an Incident Report that was received by CCL on 01/17/2024 and occurred on 01/16/2024. LPA met with Administrator, Mary Schramm, and discussed the purpose of the visit. Incident report states that Resident 1 (R1) went out the facilities front door at 10:57AM, and the front desk clerk let the Medication Technician know that R1 was leaving. Staff proceeded to search for him but were unsuccessful, so after 20 minutes of searching they called the police for assistance. R1 was eventually located by a Community Service Officer in the the locked Yacht Club at 12:14PM and was then brought back to the facility. Resident had no injuries. Per conversation with Administrator, R1 is ambulatory and moves quickly. R1's Physicians Report states that R1 has a Dementia DX. Physicians Report has conflicting information, with one section indicating that R1 is not at risk if allowed to leave the facility unsupervised, and another section indicating that R1 is at risk if allowed to leave the facility unsupervised. Review of R1's care plan dated 11/03/2023, indicated that it is required that R1 wears a wanderguard at all times. R1 was placed on frequent 2 hour status checks. It was noted in R1s care plan that R1 is unable to leave the facility unassisted. 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. Exit interview conducted. Copy of report, LIC809D, and appeal rights discussed and provided to Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Feb 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(j) · Plan of correction due date: Feb 16, 2024

87705 Care of Persons with Dementia (j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by allowing resident to exit the building unassisted, resulting in resident elopement.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Facility conducted an all staff retraining, increased supervision was implemented, and a 1:1 companion has been put in place for resident. Deficiency cleared during visit.