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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286800667
Report Date: 09/09/2021
Date Signed: 09/09/2021 10:25:50 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
07/12/2021 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210712134737
FACILITY NAME:CEDARS CARE HOME, THEFACILITY NUMBER:
286800667
ADMINISTRATOR:SHERWOOD, LAURAFACILITY TYPE:
740
ADDRESS:1520 CEDAR STREETTELEPHONE:
(707) 942-9200
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:12CENSUS: 11DATE:
09/09/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Laura Sherwood (Administrator)TIME COMPLETED:
10:40 AM
ALLEGATION(S):
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-Personal Rights

-Reporting Requirements
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.

There is an allegation of a Personal Rights violation. LPA Interviews conducted on 7/19/2021 revealed that at times resident (R1) was restricted visitors and phone use. Napa County Sheriff Report dated 7/9/2021, interviews revealed staff were instructed to not let R1 out of their room. Additional interviews conducted by Napa County Sheriff revealed that R1s movements throughout the facility at times were restricted as a punishment. Multiple interviews with residents revealed that there is food service per regulation but not a lot of alternative choices. Based on LPA’s observations, interviews and a review of records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Continues on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (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)
Page: 1 of 5
Control Number 21-AS-20210712134737
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
VISIT DATE: 09/09/2021
NARRATIVE
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Continued from LIC9099...

There is allegation of reporting requirements. Documentation dated 6/29/2021 reflects R1 was seen in the ER for a head injury. Community Care Licensing (CCL) did not receive an incident report. CCL received incident reports on 7/12/2021 and 7/14/2021 for R1 for incidents occurring on 7/4/20201. In addition, CCL received an incident report on 7/12/2021 for incident occurring on 7/1/2021 for R2. Based on LPA’s observations, interviews and a review of records, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or 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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/12/2021 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210712134737

FACILITY NAME:CEDARS CARE HOME, THEFACILITY NUMBER:
286800667
ADMINISTRATOR:SHERWOOD, LAURAFACILITY TYPE:
740
ADDRESS:1520 CEDAR STREETTELEPHONE:
(707) 942-9200
CITY:CALISTOGASTATE: CAZIP CODE:
94515
CAPACITY:12CENSUS: 11DATE:
09/09/2021
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Laura Sherwood (Administrator)TIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Facility failed to post food menu.
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.

There is an allegation facility failed to post food menu. LPA interviewed staff on 7/19/2021 who indicated the facility had a sample menu, but they cook based on resident preferences. LPA was provided with a copy of a sample menu for the facility.

There is not a regulatory requirement for menu to be posted based on current capacity. Based on LPA observation, and interview, it has been determined the complaint is 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) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (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)
Page: 3 of 5
Control Number 21-AS-20210712134737
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
CCR
87468.1(a)(6)
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87468.1 (a)(6) Personal Rights of Residents in All Facilities (a) Residents in all RCFEy shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by:
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Licensee to ensure residents personal rights are maintained. Licensee agrees to review 87468.1 (a)(6) & provide a written plan that addresses how the facility will ensure the rights of resident to move freely at the facility by POC date 9/10/21.
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Based on LPA observation, interview and record review R1’s movement was restricted at the facility. This poses an immediate risk to the health safety and personal rights of residents in care.
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Licensee agrees to obtain training from an outside source for all staff on the topic of residents’ personal rights and to ensure that residents needs are being met by 9/10/21.
Type A
09/10/2021
Section Cited
HSC
1526.269
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1569.269 Enumerated rights; severability (a)Residents of residential care facilities for the elderly shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:
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Licensee to ensure all residents are always treated with dignity & respect Licensee agrees to sign LIC 9098 attesting understanding of Health and Safety Code 15629 (a)(1) Enumerated Rights. Licensee agrees to submit a date for conducting training to all staff on regulation 1569.269(a)(1) by POC date & submit proof of training by POC due date of 9/10/21.
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Based on LPA observation, interview and record review, R1’s telephone calls and visitations were restricted. This is an immediate risk to the health, safety and rights of 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) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (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)
Page: 4 of 5
Control Number 21-AS-20210712134737
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 B
09/24/2021
Section Cited
CCR
87211
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 87211(a)(1)(D) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency...: (1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of ....(D) Any incident which threatens the welfare, safety or health of any resident....This requirement has not been met as evidenced by:
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Licensee will ensure incidents are reported within regulatory timeframes. Licensee agrees to review the requirements of 87211 and to provide CCL with a signed and dated declaration attesting to the facility's compliance going forward by POC date of 9/24/21.
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Based on records review, interviews R1 had two incidents occurring on or around 7/4/2021 & incidents were not reported within regulatory timeframes and one incident that was not reported to CCL. R2 had an incident that was not reported within regulatory timeframes. This poses a potential risk to the health & safety of resident 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) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (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)
Page: 5 of 5