286803264-12-28-2022-21-AS-KMOA-CMYR56-20230111114234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286803264
Report Date: 12/28/2022
Date Signed: 12/28/2022 12:37:21 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20221007113409

FACILITY NAME:	NAZARETH ROSE GARDEN OF NAPA		FACILITY NUMBER:	286803264
ADMINISTRATOR:	GOCO, MARISOL		FACILITY TYPE:	740
ADDRESS:	903 SARATOGA DRIVE		TELEPHONE:	(707) 252-7488
CITY:	NAPA	STATE: CA	ZIP CODE:	94559
CAPACITY:	44	CENSUS: 27	DATE:	12/28/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Admistrator, Marisol Goco		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Neglect/Lack of supervision resulting in injuries
Facility did not dispense medication as prescribed by doctor

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 12/28/2022 to conduct a complaint inspection and deliver findings regarding the allegations above. LPA met with administrator, Marisol Guinto Goco.

There was an allegation that neglect, or lack of supervision resulted in injuries to Resident 1 (R1). Reporting Party (RP) reported scratches, bruises, and bumps on resident’s head as a result of multiple falls. Review of R1’s file revealed evidence of falls and ongoing discussion with parties responsible for care to mitigate fall risk. LPA interviewed hospice representatives to discuss the use of bedrails. Per hospice representative bedrails were not utilized for R1 because he was prone to restlessness and there were concerns R1 would jump over rails or hit himself on the rails. Physician ordered that bed be placed on floor as a safety measure against falls. Although the allegation may be valid there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegation is UNSUBSTANTIATED.
Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

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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Control Number 21-AS-20221007113409

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: NAZARETH ROSE GARDEN OF NAPA	FACILITY NUMBER: 286803264
	VISIT DATE: 12/28/2022

NARRATIVE

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There was an allegation that facility did not dispense medication as prescribed by a doctor. RP reported concerns of overmedication with antipsychotic medication. LPA reviewed Medication Administration Record (MAR) for the period 09/01/2022-10/12/2022. MAR did show antipsychotic medication administration and changing of dosage on 10/07. On 10/07 the physician ordered an increase, but the higher dose was never given because it was requested that it be lowered the next day. Per hospice representative this medication predates the admission to hospice and was not a part of the hospice comfort kit. A medicated patch used for pain management was ordered on 10/11, on 10/12 that dosage was doubled. Hospice representative indicated that facility does not apply that patch. Patch was applied once on 10/11 by qualified hospice staff. Although the allegation may be valid there is not a preponderance of evidence to prove the alleged violation did or did not occur therefore the allegation is unsubstantiated.

No deficiencies cited during today's inspection.

Exit interview conducted with administrator. Copy of this report provided by email.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

LIC9099 (FAS) - (06/04)

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