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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800367
Report Date: 09/04/2020
Date Signed: 10/06/2020 10:27:40 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
05/04/2020 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200504140718
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: 17DATE:
09/04/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rolando MacaraigTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not allow the resident's authorized representative to attend a meeting regarding a change in the resident's condition.
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, via phone, with Licensee Rolando Macaraig for the purpose of delivering findings for above allegation It is being conducted via phone due to COVID - 19 precautions.

There is an allegation facility staff did not allow the resident's authorized representative to attend a meeting regarding a change in the resident's condition. According to complaint, outside party requested to be included in a meeting for R1. LPA obtained information about who was responsible for adding others to a meeting and attendees of the meeting. LPA obtained information regarding R1’s authorized party on 8/27/2020. In reference to this complaint in the allegation, outside party that requested to be part of this meeting is not R1’s authorized representative. This agency has investigated the complaint alleging facility staff did not allow the resident's authorized representative to attend a meeting regarding a change in the resident's condition. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020
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