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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803264
Report Date: 06/16/2020
Date Signed: 06/16/2020 11:02:37 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-20200603152703
FACILITY NAME:NAZARETH ROSE GARDEN OF NAPAFACILITY NUMBER:
286803264
ADMINISTRATOR:GOCO, MARISOLFACILITY TYPE:
740
ADDRESS:903 SARATOGA DRIVETELEPHONE:
(707) 252-7488
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:44CENSUS: DATE:
06/16/2020
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marisol GocoTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to provide resident records to resident's responsible party
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Progam Analyst Leibert contacted Administer, Marisol Goco, this date, for the purpose of delivering findings for the above captioned complaint. The visit was conducted by tele-visit due to the COVID - 19 precautions. LPA Leibert has conducted an investigation of the allegation by interviewing the parties and witnesses, obtaining and reviewing documents. The allegation Is denied. This Department has made the following determinations: R1 was a resident at the facility prior to death which occurred in March 2020; R1's spouse, S1, was the responsible party for R1 during R1's residency at the facility. S1 continues to reside at the facility and has stated that S1 does not want records for R1 released to the Complainant. Complainant has requested records for R1 and submitted a Declaration of Successor Interest and a HIPPA compliant release in favor of the Complainant. Administrator has not provided the requested records based upon the believe that S1 is the responsible party and has requested further verification of Complainant's authority to receive the requested documents. This Department has investigated the claims and differing opinions of this issue. Based upon interviews and documents reviewed, it is determined that although the allegation may be true, there is not a preponderance of evidence to prove violation did, or did not, occur. Therfore, 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: 06/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2020
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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