216804035-3-13-2023-21-AS-CMAZ-CQBS3H-20230327133108

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804035
Report Date: 03/13/2023
Date Signed: 03/13/2023 09:31:09 AM

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
01/18/2023 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230118164859

FACILITY NAME:	ROSES RESTHOME		FACILITY NUMBER:	216804035
ADMINISTRATOR:	DANIEL, SILVANA		FACILITY TYPE:	740
ADDRESS:	1 ROOSEVELT AVE		TELEPHONE:	(415) 479-5522
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	8	CENSUS: 5	DATE:	03/13/2023
		UNANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Silvana Daniel (Licensee)		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

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Staff not administering medications to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to initiate a complaint investigation regarding the allegation listed above and met with Administrator Silvana Daniel.

It was alleged that staff was not administering medications to resident (R1). Reporting party concerns were that Administrator is refusing to give R1 their pain medication when R1 is in pain at all times. After reporting party inquired about this situation with Administrator who have allegedly stated their acknowledgement that R1 has not been receiving pain medications because Administrator does not believe in pain medications and R1 doesn't look like they are in pain. Through the process of this investigation the LPA reviewed records and interviewed staff. On 1/23/23 LPA conducted interviews with Administrator who stated that even though they don’t believe that certain medication was needed by R1, the medication was given to R1 as ordered by their Physician. R1 passed away on 1/3/23 while receiving hospice services. LPA reviewed medication records related to medication administration.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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-20230118164859

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: ROSES RESTHOME	FACILITY NUMBER: 216804035
	VISIT DATE: 03/13/2023

NARRATIVE

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Continued from LIC9099...

Based on records review of R1’s hospice plan of care, hospice staff training plan including medication administration, hospice visit communication log dated 7/12/22 to 1/3/23 including volunteer visit communication log dated 7/11/22 to 12/30/22, centrally stored and destruction records. There was no supporting evidence to show that a resident’s (R1) medication was not managed appropriately nor any missing medications. LPA attempted using different ways to contact complainant to obtain additional information, but complainant’s contact information provided was wrong. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

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