216804035-5-16-2023-21-AS-HDBI-CRWTF4-20230517144054

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216804035
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:17:38 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
03/03/2023 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230303161557

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: 7	DATE:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	12:29 PM
MET WITH:	Silvana Daniel (Licensee)		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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-Staff did not seek medical attention to resident in care.
-Staff did not turn resident resulting in pressure injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Licensee Silvana Daniel to deliver findings regarding the complaint allegation above.

There was an allegation of Staff did not seek medical attention to resident in care. Per Reporting Party, resident (R1) was admitted to the Emergency Department of Marin Health for pain related to wounds. R1 was on Hospice prior to hospitalization. R1’s responsible party have revoked hospice services and brought R1 for treatment disclosing not taking R1 to medical appointments due to R1's limited mobility and been ineligible to receive transportations resources from the Veterans Affair (VA). Also, it was disclosed that R1 has been bedbound since January 2023. Based on records review, On 5/5/23, LPA learned through R1’s hospice records provided by hospice agency indicating that R1 was admitted to hospice services since 11/22/22 and had been seen by a hospice nurse until their discharged and hospital admission date of 03/01/23 due to needed care of wounds beyond hospice services. 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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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-20230303161557

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: 05/16/2023

NARRATIVE

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Continued from LIC9099…

Per hospice records, hospice nurses were in constant communication with facility staff and R1’s responsible party attempting to arrange doctor’s appointments through the VA regarding wound care needed beyond hospice services. During confidential interviews with facility staff, hospice nurses and responsible party it was confirmed that R1 had been provided with the medical care needed. Also, records review did not provide any supporting evidence to prove that staff did not seek medical attention for R1 allegation which is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

Regarding allegation of Staff did not turn resident resulting in pressure injuries. Per Reporting Party, R1 was admitted to Marin Health due to a non-healing forehead lesion that continues to increase in size and pain related to wounds caused by facility staff not been able to reposition R1 as necessary. During the investigation, LPA conducted confidential interviews and reviewed facility records for R1. Based on records review, R1 was admitted to hospice services and had been seen by a hospice nurse in average of two times per week until been discharged on 03/01/23 due to needed care of wounds beyond hospice services. According to hospice care notes, facility staff was also providing care and there were no concerns raised regarding R1’s care needs been met by facility staff. Confidential interviews with involved parties confirmed that R1 had been diagnosed with terminal degenerative disease of nervous system and as of January 20, 2023. R1 developed wounds in their feet. However, hospice nurse and R1’s responsible party corroborate that facility staff were repositioning and providing care to R1’s wounds as instructed by doctor’s order. A finding that the complaint allegations “Staff did not turn resident resulting in pressure injuries” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today’s visit.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

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