216803761-10-15-2024-21-AS-VBEI-DABQ53-20241023115116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803761
Report Date: 10/15/2024
Date Signed: 10/15/2024 09:41:45 AM

Unsubstantiated

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
07/25/2024 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20240725132325

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: CA	ZIP CODE:	94901
CAPACITY:	47	CENSUS: 21	DATE:	10/15/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Executive Director, Frank Nola, and Administrator, Jolly Carungcong		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Facility Staff hit resident in care

INVESTIGATION FINDINGS:

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At approximately 9:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegation and met with Executive Director, Frank Nola, and Administrator, Jolly Carungcong. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations.

The following allegation was investigated, “Facility staff hit resident in care.” Complainant alleged that on 07/23/2024, facility staff was seen striking Resident 1 (R1). Complainant stated that incident was seen from the street through R1’s window.The Department conducted interviews with staff and involved parties, reviewed police report and made observations. Complaint alleges that staff were observed hitting a resident in care. Interviews conducted with involved parties stated that during a visit conducted on 07/25/2024, R1 did not have any visible signs of injury or bruising observed.

Continued on LIC9099C

Unsubstantiated

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: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

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-20240725132325

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: 10/15/2024

NARRATIVE

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Continued from LIC9099

Photographs of R1 provided to the Department showed that R1 had yellow discoloration on their forehead from March, April and June 2024 which was before the alleged incident of July 2024. Facility documents reviewed indicated that the facility documented when R1 was observed to have skin changes, and that R1’s responsible party was notified appropriately. Interview conducted with Administrator and correspondence provided stated that R1’s Primary Care Physician believed that the discoloration from March, April and June 2024 could be from R1’s medication. Staff denied allegation that they hit the resident. Staff interviews and witness statement provided conflicting information and LPA was unable to confirm that the allegation occurred. Therefore, this allegation is Unsubstantiated.

A finding that the complaint allegation 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 Executive Director and Administrator. 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: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024

LIC9099 (FAS) - (06/04)

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