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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800367
Report Date: 12/16/2020
Date Signed: 12/16/2020 04:40:38 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
02/19/2020 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200219112105
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:
12/16/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Alex MacaraigTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not giving medication to resident per physician orders
Facility does not have enough staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact this date, by phone, with Assistant Administrator Alex Macaraig, for the purpose of delivering findings for above allegations. It is being conducted by phone due to COVID - 19 precautions.

There is an allegation staff are not giving medication to resident per physician orders. LIC 602 dated 12/19/2019 for R1 indicates R1 can manage their own medication. The Appraisal dated 4/29/2020 indicates facility will manage all aspects of medication. Medical records review of Physician Office Consult forms dated 9/27/2020, 9/28/2020, and 9/29/2020 revealed medications were not administered between 4/2020 to 9/2020. Based on LPAs observations and interviews conducted and record review(s) between 12/12/2020 and 11/4/2020, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

(See 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020
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 6
Control Number 21-AS-20200219112105
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: 12/16/2020
NARRATIVE
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 There is an allegation facility does not have enough staff. When interviewed on 2/27/2020 S2 indicated, they had been left alone at the facility for about 10-15 minutes. When interviewed on 2/27/2020, R4 indicated, the staffing level had gone down before Christmas, some people are just waiting and waiting. R5 has to wait a long time to get from the dining table to room or bedroom. LPA observed R5 had to wait 20 minutes once meal was finished to be taken from dining table to their bedroom and was not acknowledged by staff. During interview on 2/27/2020, R6 indicated, staffing seemed to have gone down. Staffing schedules contradict LPA observations. Documentation dated 4/25/2020 reflects; Licensee is not able to pick up patient as they are the only one at the facility. Record review indicated 11 out of 16 residents are non-ambulatory.

Based on LPAs observations and interviews conducted and record review(s) between 12/12/2020 and 6/8/2020, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.

(See 9099-D)

Signature on File.

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

DATE: 12/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/19/2020 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200219112105

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:
12/16/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Alex MacaraigTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff do not respond to resident's call button in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact this date, by phone, with Assistant Administrator, Alex Macaraig, for the purpose of delivering findings for above allegation. It is being conducted by phone due to COVID - 19 precautions.

Although complainant alleges staff do not respond to resident's call button in a timely manner, based on LPA observation, interview and record review there was no additional information to substantiate the allegation. Resident call buttons were tested on 2/272020, and staff responded in less than a minute. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No citations issued. 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: 12/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20200219112105
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2020
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met as evidenced by:
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Licensee agrees to ensure adequate staffing to meet resident needs. Administrator/Licensee agrees to submit a staffing plan to meet current census of resident needs by 12/21/2020.
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Based on LPA observation, interview and record review, Licensee did not ensure staff were sufficient to respond to potential resident needs. This poses an immediate health, safety or personal rights risk to residents in care.
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Type B
12/16/2020
Section Cited
CCR
87465(b)
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87465 Incidental Medical and Dental Care Services. (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication.., facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.
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Licensee agrees ensure residents have accurate documentation to reflect care needs. Administrator/Licensee agrees to update care plan information to determine R1’s needs. Licensee agrees to updated LIC 602 to reflect R1’s care needs and submit to LPA by 12/30/2020.
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This requirement is not met as evidenced by: Based on LPA observation, interview and record review, facility did not ensure documentation was consistent with R1's care needs. medications were filled per doctor's order. This poses a potential risk to the health, safety or personal rights to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20200219112105
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2020
Section Cited
CCR
87465(c)(2)
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87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
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Licensee agrees to ensure residents medications are being administered per physician's order. Administrator/Licensee will design a procedure regarding resident medications are being administered per physician's order. Procedure to be submitted to CCL by POC date of 12/30/2020.
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Based on LPA observation, interview and record review medications were not administered per doctor's order. This poses a potential risk to the health, safety or personal rights to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 6