286800667-9-9-2021-21-AS-BMOS-C6QNJK-20210910103028

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286800667
Report Date: 09/09/2021
Date Signed: 09/09/2021 10:13:11 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
07/08/2021 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210708133830

FACILITY NAME:	CEDARS CARE HOME, THE		FACILITY NUMBER:	286800667
ADMINISTRATOR:	SHERWOOD, LAURA		FACILITY TYPE:	740
ADDRESS:	1520 CEDAR STREET		TELEPHONE:	(707) 942-9200
CITY:	CALISTOGA	STATE: CA	ZIP CODE:	94515
CAPACITY:	12	CENSUS: 11	DATE:	09/09/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Laura Sherwood (Administrator)		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility staff physical abused resident in care

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation that facility staff physically abused a resident in care. Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of delivering findings of the investigation and met with Administrator, Laura Sherwood.

It was reported a staff (S1) pushed R1 resulting in R1 falling, S1 proceeded to kick and hit R1 with a shoe. Based on documentation dated 8/25/2021 staff admitted to pushing R1 from behind as well as kicking and hitting R1 with a shoe. Video evidence from 7/04/2021 revealed S1 grabbing and pushing R1 towards the laundry room at which point R1 falls to the ground. Video evidence also shows two staff (S1 & S2) grabbing R1 by the arm and shirt and dragging R1 in the direction of R1’s bedroom. Review of additional video surveillance revealed a second incident on 6/29/2021 involving S1 pulling R1 away from the dining room table, resulting in R1 falling. The Department obtained photo evidence of multiple bruises on R1s body. Based on observations, interviews and a review of records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. An immediate civil penalty in the amount of $500 assessed due to a violation resulting in injury of R1. The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

Substantiated

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: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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-20210708133830

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: CEDARS CARE HOME, THE	FACILITY NUMBER: 286800667
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/10/2021 Section Cited HSC 1569.269	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee will ensure resident’s rights are maintained. Licensee agrees to provide LIC9098 notifying CCL that Elder Abuse prevention training from an outside vendor has been scheduled by POC due date of 9/10/21.
	8 9 10 11 12 13 14	This requirement was not met as evidence by: Based on the Department’s investigation R1 was the victim of elder abuse by staff which poses an immediate risk to the health, safety and Personal Rights of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC9099 (FAS) - (06/04)

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