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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803264
Report Date: 07/17/2020
Date Signed: 07/17/2020 04:10:43 PM



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
09/06/2019 and conducted by Evaluator Angela Elliott
COMPLAINT CONTROL NUMBER: 21-AS-20190906121357
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: 28DATE:
07/17/2020
ANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marisol GocoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff handling residents in a rough manner.
Residents sustaining multiple bruises.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via tele-visit, with Executive Director, Marisol Goco, for the purpose of delivering findings for above allegations. It is being conducted via tele-visit due to COVID - 19 precautions.

There is an allegation staff are handling residents in a rough manner. LPAs interview with staff (S1) on 2/3/2020 revealed staff at times can be rough with residents out of frustration. Examples were provided such as observations of staff pulling residents while putting them into chairs. LPA interviewed R1 on 2/21/2020 and R2 and R3 on 2/11/2020 who informed LPA they have experienced and observed staff handling residents in a rough manner. Based on LPA observation, record review and interview the allegation of staff handling residents in a rough manner is substantiated, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.
(See 9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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 5
Control Number 21-AS-20190906121357
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: NAZARETH ROSE GARDEN OF NAPA
FACILITY NUMBER: 286803264
VISIT DATE: 07/17/2020
NARRATIVE
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There is an allegation of residents sustaining multiple bruises. Bruising was indicated on care notes for R1 (9/19/2019) and was determined to be self-inflicted. Resident physical evaluation for R1 (7/22/2019-7/23/2019) indicates bruising and was attributed to a fall. Resident’s physical evaluation for R2 dated 8/14/2019 documents bruising resulting from a fall. There is documentation to support multiple discolorations for R3 (Daily observation and Monitoring worksheet 9/2/2019-photos obtained). R3 no longer resides at the facility as of 9/2019, LPA was unable to interview R3 to obtain additional information. There is an allegation R4 sustained unexplained bruising which was brought to the Departments attention on 9/30/2019 and was investigated. LPAs interviews with staff and residents revealed staff are handling residents in a rough manner. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Deficiencies 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. Appeal Rights Given.

(See 9099-D)

***Civil Penalty Assessed in the Amount of $250.00 for repeat violation within the last 12 months.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20190906121357
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: NAZARETH ROSE GARDEN OF NAPA
FACILITY NUMBER: 286803264
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/17/2020
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Administrator agrees to submit evidence of staff training regarding documenting any resident injuries and elevating any concerns to prevent future injuries by POC due date of 7/18/2020.
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Based on LPA’s investigation, record review, and interviews with staff, facility did not ensure the safety of residents in care, it was determined residents are handled in a rough manner resulting in bruising which is an immediate health, safety or personal rights risk to residents in care. ***Civil Penalty of $250.00 for repeat violation in the last 12 months
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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) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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
09/06/2019 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20190906121357

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: 28DATE:
07/17/2020
ANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marisol GocoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff hitting residents.
Staff yell at residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact on this date, via televisit with Executive Director, Marisol Goco, for the purpose of delivering findings for above allegations. It is being conducted via televisit due to COVID - 19 precautions.

It is alleged staff hitting residents. Based on LPA interviews conducted on 2/21/2020, R1 indicated they had been hit by a staff in the past and R2 made a hitting motion to their leg and nodded “yes” when asked if staff had ever hit them. Both residents have a primary diagnosis of Alzheimer’s/Dementia. No other information was obtained through interviews with staff, record review or observation conducted between 9/12/2020 and 2/21/2020 to provide corroborative information of the allegation that staff hit residents. This department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation did or did not occur. Therefore, the allegation is UNSUBSTANTIATED.


(See 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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 5
Control Number 21-AS-20190906121357
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: NAZARETH ROSE GARDEN OF NAPA
FACILITY NUMBER: 286803264
VISIT DATE: 07/17/2020
NARRATIVE
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It is alleged staff yell at residents. Based on LPA interviews with staff and residents, record reviews, and observations between 9/12/2019 and 2/21/2020, there is no additional information to support staff yell at residents. There were no other witnesses, or supporting evidence obtained. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5