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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803041
Report Date: 10/21/2020
Date Signed: 10/21/2020 11:39:54 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
06/03/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200603145211
FACILITY NAME:LA HOMA GUEST HOME, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:RICASTA, JOCELYNFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: DATE:
10/21/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jocelyn RicastaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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A staff spoke inappropriately to a resident in care
Staff are not meeting residents care needs
Facility did not comply with reporting requirements
Staff did not provide timely medical attention


INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Jocelyn Ricasta for the purpose of delivering finding on the above captioned complaint allegations. Contact was made via Tele - Visit due to the COVID - 19 precautions. LPA did not physically present on site. This Department has investigated the complaint by obtaining and reviewing documents and by interviewing witnesses. The following determinations have been made: Witness # 1 and witness # 3 observed Staff (S1) speak to R1 in a rude and inappropriate manner; Three witnesses report being told by R1 that R1 fell on or about 5/1/2020 and remained on the floor for several hours during the night before being provided assistance by staff; No record of this incident was reported to CCL by the facility as required by Title Twenty-Two regulation. R1's physician's Assessment Report dated October 2019 indicates that R1 was not confused or disorientated and able to follow instructions and communicate needs. Based upon witness statements and records reviewed, this agency finds that the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
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 4
Control Number 21-AS-20200603145211
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: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2020
Section Cited
CCR
87466
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87466 Observation of the Resident .
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. ***Based upon witness statements, this requirement has not been met as evidenced by:
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Administration to provide a written plan with protocols ensuring that residents are frequently observed during the night time hours. Plan to be submitted to CCL for approval and clearance of the deficiency by the POC date.
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On or about May 1, 2020, R1 fell and remained on the floor for several hours at night before staff provided assistasnce the next morning. This posed an immediate risk to the health of R1.
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Type A
10/26/2020
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. ****Based upon witness statements, this requirement has not been met as evidenced by:
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Administration to provide personal rights training to all staff and to provide proof of correction to CCL by POC date in order to clear the deficiency.
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Two witnesses observed S1 speak rudely and inappropriately to R1. This posed an immediate risk to the personal rights of the resident.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20200603145211
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: LA HOMA GUEST HOME, LLC
FACILITY NUMBER: 286803041
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2020
Section Cited
CCR
87211(a)(D)
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87211(a)(1)(D) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of ....Any incident which threatens the welfare, safety or health of any resident....Based upon statements taken and records reviewed, this requirement has not
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Administrator 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. In order to clear the deficiency, submit to CCL by the POC date.
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been met as evidenced by: R1 fell on or about 5/1/2020 and remained on the floor for several hours. No report of this incident was received by CCL. This posed a potential risk to the safety, health, and personal rights of R1.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
06/03/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200603145211

FACILITY NAME:LA HOMA GUEST HOME, LLCFACILITY NUMBER:
286803041
ADMINISTRATOR:RICASTA, JOCELYNFACILITY TYPE:
740
ADDRESS:1161 LA HOMA DRIVETELEPHONE:
(707) 252-7426
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: DATE:
10/21/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jocelyn RicastaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained injuries while in care due to lack of supervision

INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Joceln Ricasta for the purpose of delivering findings on the above captioned complaint allegations. Contact was made via Tele - Visit due to the COVID - 19 precautions. LPA did not physically present on site. This Department has investigated the complaint by obtaining and reviewing documents and by interviewing witnesses. The following determinations have been made: R1 has fallen at the facility and sustained injuries, including skin tears; Complainant alleges lack of supervision caused the injuries; witnesses have observed one to three staff on duty at various times; R1 is non ambulatory and has attempted to ambulate alone; R1 has a history of skin breakdown pre dating placement at the facility; R1's physician has noted motor impairment. Based upon the statement of witnesses and records review, it cannot be determined if lack of supervision was the causal factor in R1's injuries. Although the allegation may be true, or is valid, there is not a preponderance of evidence to prove the allegation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4