216803761-9-18-2024-21-AS-VBEI-D9E2H6-20240923172415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803761
Report Date: 09/18/2024
Date Signed: 09/18/2024 11:22:51 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
09/13/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240913093214

FACILITY NAME:	GREENWOOD ASSISTED LIVING		FACILITY NUMBER:	216803761
ADMINISTRATOR:	JOLLY CARUNGCONG		FACILITY TYPE:	740
ADDRESS:	233 WEST END AVE		TELEPHONE:	(415) 258-1560
CITY:	SAN RAFAEL	STATE:	ZIP CODE:	94901
CAPACITY:	47	CENSUS: 21	DATE:	09/18/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director, Frank Nola, and Administrator, Jolly Carungcong		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Lack of supervision

INVESTIGATION FINDINGS:

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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias and Licensing Program Manager (LPM) Victoria Bertozzi arrived unannounced to initiate a Complaint Investigation regarding the above allegation and met with Executive Director, Frank Nola, and Administrator, Jolly Carungcong.

LPA and LPM requested and reviewed documents and conducted interviews.

Complaint alleges that Resident 1 (R1) was observed lying in the road bleeding and unresponsive near the facility. Report indicated that a witness knocked on the facility door but no one came so they returned to the resident and called 911. It was reported that a second witness arrived and also attempted to knock on the facilty door with no response. Eventually an individual exited the building so a witness was able to make contact with facilty staff who then came outside and responded.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

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 3

Control Number 21-AS-20240913093214

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
	VISIT DATE: 09/18/2024

NARRATIVE

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Continued from LIC9099C

R1 was transported to the hospital. CCL staff confirmed that R1 does have a dementia diagnosis and is not able to leave the facility unassisted. Per interview with Administrator, it appears that R1 eloped from the courtyard that has a gate that leads outside of the facility. Facility's response was to padlock the exterior gates of the facility. CCL staff notified the Administrator that locking exit doors in that manner is a fire clearance violation and requested that facility have the fire department come out to determine if the padlocks are permitted. This allegation is Substantiated.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Exit interview conducted. Copy of report, LIC809D, LIC811 (Confidential Names), Plan of Corrections, and Appeal Rights discussed and provided to Administrator and Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240913093214

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/19/2024 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia: (b) In addition to the requirements as specified in Section 87208... plan of operation shall address... residents with dementia, including: (2) Safety measures to address behaviors such as wandering... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit a written plan of updated procedures for elopement prevention and provide response from fire department regarding the padlocks on exterior gates by POC due date of 9/19/2024
	8 9 10 11 12 13 14	Based on documents reviewed, the Licensee did not comply with the section cited above. Resident 1 (R1) eloped from facility. R1’s Physician Report states they have dementia and are unable to leave unassisted. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024

LIC9099 (FAS) - (06/04)

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