286800367-2-18-2021-21-AS-BMOS-BYJQ9T-20210224105850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286800367
Report Date: 02/18/2021
Date Signed: 02/18/2021 03:21:24 PM

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
05/28/2020 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200528160435

FACILITY NAME:	COUNTRY INN		FACILITY NUMBER:	286800367
ADMINISTRATOR:	MACARAIG, ROLANDO		FACILITY TYPE:	740
ADDRESS:	1109-B LA GRANDE AVENUE		TELEPHONE:	(707) 252-3392
CITY:	NAPA	STATE: CA	ZIP CODE:	94558
CAPACITY:	29	CENSUS: 10	DATE:	02/18/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Alex Macaraig		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff is retaliating against a resident
Facility staff is serving a poor quality of food

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Elliott made contact this date, by phone, with Director Of Operations, Alex 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 that facility staff is serving a poor quality of food. LPA reviewed records, conducted interviews, and made observations of the facility. On 11/5/2020 LPA virtually toured the kitchen area with Assistant Administrator, Shannon Gayski and Director of Operations, Alex Macaraig where at least one week of perishable food and 2 day of non-perishable foods was observed. LPA did not observe any spoiled or expired food. Menu observed at the facility was current. Conflicting interviews were obtained from R1 regarding quality of food at the facility. 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.

(See LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

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-20200528160435

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: 02/18/2021

NARRATIVE

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There is an allegation facility staff is retaliating against a resident. LPA made observations, reviewed documentation and conducted interviews including responsible party which revealed conflicting information regarding resident being retaliated against. Complainant provided information staff are making it challenging for resident. No further information was obtained to support allegation. R1 moved to a new facility at the beginning of 2021. 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. Signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC9099 (FAS) - (06/04)

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