<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800367
Report Date: 06/18/2020
Date Signed: 06/23/2020 07:45:13 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2019 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20191212152305
FACILITY NAME:COUNTRY INNFACILITY NUMBER:
286800367
ADMINISTRATOR:MACARAIG, ROLANDOFACILITY TYPE:
740
ADDRESS:1109-B LA GRANDE AVENUETELEPHONE:
(707) 252-3392
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:29CENSUS: 16DATE:
06/18/2020
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rolando MacaraigTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility abandoned resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Angela Elliott made contact this date, by phone, with Licensee, Rolando Macaraig, for the purpose of delivering findings for above allegation. It is being conducted by phone due to COVID - 19 precautions.

There is an allegation facility abandoned resident. Documentation dated 12/10/2019 indicated R1 went to emergency room and facility was unable to pick up R1. R1’s conservator made transportation arrangements to return to the facility. Review of R1’s Identification and Emergency Contact Information revealed inaccurate information. Based on LPA documentation review, interview and observations between 3/20/2020 and 4/27/2020, there is no evidence to support the allegation the facility abandoned resident; therefore, the allegation is UNSUBSTANTIATED. UNSUBSTANTIATED means 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. Signature on file.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020
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 2
Control Number 21-AS-20191212152305
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: COUNTRY INN
FACILITY NUMBER: 286800367
VISIT DATE: 06/18/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Although Complainant alleges facility abandoned resident, information obtained during the course of the investigation revealed R1 was transported to the hospital by unauthorized party, date was unable to be obtained by unauthorized party. LPA will address transportation services in the event of medical needs on a case management inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2