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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803041
Report Date: 03/05/2021
Date Signed: 03/05/2021 11:13:51 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
08/12/2020 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200812085733
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: 5DATE:
03/05/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jocelyn RicastaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident left in soiled diapers and unkempt

Resident's hygiene needs were not being met

INVESTIGATION FINDINGS:
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold contacted Administrator Jocelyn Ricosta to deliver investigative findings for the above allegations. This visit is being conducted by telephone due to Covid-19 precautions. Based on interviews conducted and records reviewed, at the time resident was admitted to the hospital on 08/06/2020, they were observed to have dirty and matted hair, wearing a soilded diaper, a secondary pad and resting on multiple chux pads with various stages of being soiled. Resident was observed to have a foul smelling pressure injury that was draining yellow green fluids. Interviews conducted indicated the appearance of the resident showed signs of neglect. Facility was previously cited on 10/21/2020 regarding observation of a resident. ***A civil penalty is being issued in the amount of $250 for a repeat violation.***

Continued on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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-20200812085733
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: 03/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2021
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...and that appropriate assistance is provided when such observation reveals unmet needs. Based upon witness
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Administration to provide a written plan with protocols ensuring that residents are frequently observed for changes in condition for all shifts.
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statements, this requirement has not been met as evidenced by: Resident was admitted to ER with matted hair and sitting on multiple chux pads of various saturation. This poses an immediate Health risk to residents in care. This is a repeat violation, a $250 civil penalty is being issued.
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Plan to be submitted to CCL for approval and clearance of the deficiency by the POC date.
CCR
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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: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20200812085733
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
VISIT DATE: 03/05/2021
NARRATIVE
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Based on LPA’s observations, interviews conducted 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.

The Department will schedule a subsequent meeting with Licensee to address continued areas of of non-compliance and concern.

This report was reviewed with Administrator and Appeal rights were given.

Original signature on file.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
08/12/2020 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200812085733

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:
03/05/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jocelyn RicastaTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility retained a resident requiring a higher level of care


Resident's pressure injury worsened while in care
INVESTIGATION FINDINGS:
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At approximately 11:00AM, Licensing Program Analyst (LPA) Chris Arnhold contacted Administrator Jocelyn Ricosta to deliver investigative findings for the above allegations. This visit is being conducted by telephone due to Covid-19 precautions. Based on interviews conducted and records reviewed, LPA was not able to determine if the resident required a higher level of care prior to being sent to the hospital. Based on interviews, a home health agency was involved in the care of resident and resident was sent to the hospital after the nurse recommended treatment was needed. Documents reviewed indicated the healthcare needs of the resident were within regulation for the period of time they were a resident of this facility. When the needs of the resident changed, the resident was sent to the hospital. There was no documentation in the resident file regarding what health care needs have changed on a daily basis. There were no daily care notes regarding the status of the pressure injury. Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
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 5
Control Number 21-AS-20200812085733
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
VISIT DATE: 03/05/2021
NARRATIVE
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Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Original Signature on file.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5