216801028-4-25-2023-21-AS-KMOA-CRAMRT-20230427095051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801028
Report Date: 04/25/2023
Date Signed: 04/25/2023 02:24:34 PM

Unsubstantiated

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
03/06/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230306134529

FACILITY NAME:	DRAKE TERRACE		FACILITY NUMBER:	216801028
ADMINISTRATOR:	RICARDO ROMERO		FACILITY TYPE:	740
ADDRESS:	275 LOS RANCHITOS ROAD		TELEPHONE:	(415) 491-1935
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	130	CENSUS: 125	DATE:	04/25/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Assisted Living Director, Mary Ann De Lara, and Resident Relations Director, Arlene Samonte		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

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Neglect/Lack of Supervision resulted resident falls with injury(ies).

INVESTIGATION FINDINGS:

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At approximately 1:45PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with met with Assisted Living Director, Mary Ann De Lara, and Resident Relations Director, Arlene Samonte. Executive Director/Administrator, Ricardo Romero, was available by telephone.

During the course of the Investigation, Licensing Program Analyst (LPA) Felias reviewed and requested documents and conducted interviews. There is an allegation of Neglect/Lack of Supervision resulting in resident falls with injury(ies). The Reporting Party (RP) reported that on 02/27/2023, Resident 1 (R1) had an unwitnessed fall resulting in R1 going to the hospital. While at the hospital, R1 was diagnosed with multiple fractures. RP also reported that this was R1’s second time falling at the facility in a month. Record Review indicated that R1 received a new Physician’s Report on 03/04/2023 and a new Care Plan on 03/06/2023 due to changes in condition.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230306134529

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: DRAKE TERRACE	FACILITY NUMBER: 216801028
	VISIT DATE: 04/25/2023

NARRATIVE

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Continued from LIC9099

R1’s Physician Report, dated 7/29/2021, stated that they had motor impairment, used an assistive walking device, and was able to independently toilet themselves without assistance. R1’s Care Plan dated, 9/14/2022, stated that R1 needed reminders to use their walking device, and that they had poor balance. Record Review also showed that R1 received Physical Therapy during the months of December 2022 and January 2023 to assist R1 with their gait and balance. Review of R1’s Facility Chart Notes indicated that the facility was monitoring R1 appropriately and communicated with their Physician and Responsible Party when needed. Facility correspondence dated, 01/09/2023, 01/30/2023, 02/01/2023, 02/02/2023, and 02/06/2023, showed that the facility was communicating with R1's Responsible Party regarding R1. Facility and R1's Responsible Party agreed that R1 would relocate to Memory Care due needing a higher level of care and supervision from falls.

A finding that the complaint allegation of “Neglect/Lack of Supervision resulted resident falls with injury(ies)" is UNSUBSTANTIATED.

A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC9099 (FAS) - (06/04)

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