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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216804035
Report Date: 12/16/2022
Date Signed: 12/16/2022 12:42:44 PM

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
10/31/2022 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20221031163205
FACILITY NAME:ROSES RESTHOMEFACILITY NUMBER:
216804035
ADMINISTRATOR:DANIEL, SILVANAFACILITY TYPE:
740
ADDRESS:1 ROOSEVELT AVETELEPHONE:
(415) 479-5522
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:8CENSUS: 7DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Silvana DanielTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Furniture in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above-mentioned complaint allegation and met with Licensee, Silvana Daniel.

Furniture in disrepair - Complaint alleges that an unstable chair was observed at the dining room table. Per interviews, a visitor sat on the chair and indicated it was wobbly. Interview indicates that staff were told and responded that they would fix the chair later but visitor insisted that the chair was removed from the dining room. Per interview with Licensee, the chair needed to be tightened and it is fine now. LPA observed during visit on 11/10/2022 that all chairs were stable. LPA confirmed through interviews that nobody was hurt.

The allegation that Furniture is in disrepair is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
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
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
10/31/2022 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20221031163205

FACILITY NAME:ROSES RESTHOMEFACILITY NUMBER:
216804035
ADMINISTRATOR:DANIEL, SILVANAFACILITY TYPE:
740
ADDRESS:1 ROOSEVELT AVETELEPHONE:
(415) 479-5522
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:8CENSUS: 7DATE:
12/16/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee, Silvana DanielTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Staff did not have records of residents medical documentation
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above-mentioned complaint allegation and met with Licensee, Silvana Daniel.

During investigation LPA conducted interviews, reviewed documents and made observations.

Staff did not have records of residents medical documentation - Complaint alleges that facility did not have the proper documentation available during a recent vaccination clinic. During interviews, LPA was told that there was a male resident who did not receive their vaccination due to the paperwork not being complete. LPA review of vaccination cards indicates that 5 of 6 residents received their vaccination. The resident who did not have a completed card was female. Per conversation with Licensee, the sixth resident did receive their vaccination and Licensee is unsure why the card wasn't updated.

A finding that the complaint allegation that Staff did not have records of residents medical documentation was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20221031163205
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: ROSES RESTHOME
FACILITY NUMBER: 216804035
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on interviews, facility had an unstable
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Facility has fixed the chair. Deficiency is clear.
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chair in the dining room. This is a potential risk to the health and safety of 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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria BertozziTELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3