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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286803264
Report Date: 11/12/2020
Date Signed: 11/12/2020 03:52:19 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
03/12/2020 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200312165657
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: 30DATE:
11/12/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marisol GocoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not provide adequate supervision.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via phone, with Administrator, Marisol Goco for the purpose of delivering findings for above allegation. It is being conducted via phone due to COVID - 19 precautions.

There is an allegation staff did not provide adequate supervision. Multiple interviews confirmed R1 AWOL’d from the facility on 2/17/2020. Administrators interview on 6/17/2020 revealed side door alarm was off and R1 got out through the iron gate which was unlocked was the likely cause. R1 was missing for a few hours and was returned to the facility by an outside party. Physician’s Assessment dated 2/13/2020 for R1 indicated R1 has wandering behavior and cannot leave the facility unassisted. There is no documentation to support police were notified about the incident. R1 was transferred to another facility the next day. 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.

(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: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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-20200312165657
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: 11/12/2020
NARRATIVE
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***Amended to reflect Civil Penalty Amount of $250.00 for repeat violation.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

***Civil Penalty issued for $250.00 for repeat violation within the last 12 months.

(See 9099-D)
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela ElliottTELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20200312165657
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: 11/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/12/2020
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Administrator agrees to ensure care and supervision of residents. Administrator agrees to provide staff training on elopement/AWOL protocols and staff training on resident elopement/wandering behaviors at the facility Administrator agrees to send date of training by COB 11/13/2020 and proof of training by COB 11/25/2020.
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Based on LPA record review, and interview, staff did not provide supervision to R1 resulting in R1 leaving the facility. The absence of supervision is an immediate risk to the Health, Safety and Rights of residents in care. ******Amended Civil Penalty Amount.***Civil Penalty assessed in the amount of $250.00 for repeat violation within the last 12 months.
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Facility plan to be development to avoid future AWOL of residents. Date of staff training on plan to be submitted by COB 11/13/2020. Proof of training as well as facility AWOL prevention plan to be submitted to CCL by COB 11/25/2020.
Type B
11/12/2020
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements- (a) Each licensee shall furnish to the licensing agency such reports..(1)A written report shall be submitted to the licensing agency…within seven days…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:
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Administrator to ensure incidents are reported to CCL according to regulation. Administrator agrees to train all staff on reporting requirements and submit proof of training by COB 11/25/2020.
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Based on LPA observation, interview and record review an incident report was not sent into CCL when R1 went AWOL from the facility. This is a potential risk to the health, safety and personal rights of residents in care.
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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: 11/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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
03/12/2020 and conducted by Evaluator Angela Elliott
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200312165657

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: 30DATE:
11/12/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Marisol GocoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Staff did not inform resident's authorized representative of incident involving resident.
Resident sustained bruises while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via phone, with Administrator, Marisol Goco for the purpose of delivering findings for above allegations. It is being conducted via phone due to COVID - 19 precautions.

Complainant alleges staff did not inform resident's authorized representative of incident involving resident R2 (photo obtained). Complainant alleges R2 fell and sustained bruises. LPA was provided information of staff alleged to be involved with R2’s fall. LPA’s interview with staff revealed conflicting information. LPA was unable to identify or verify through record review, and interviews with staff that a fall occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) 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: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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-20200312165657
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: 11/12/2020
NARRATIVE
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Complainant alleges resident sustained bruises while in care (photos obtained). Based on interviews with staff, and record review LPA was unable to obtain additional information to support R2 had a fall that would prompt notification of responsible party. LPA reviewed R2’s care notes dated 2/72020-4/14/2020 and monitoring logs dated 2/6/2020-2/29/2020. Although the complainant alleges bruises were sustained, LPA was unable to obtain additional information to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) 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: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5