286803264-11-2-2021-21-AS-BMOS-C8LNS3-20211109094225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286803264
Report Date: 11/02/2021
Date Signed: 11/02/2021 10:48:20 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
07/06/2021 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210706162313

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: 34	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Minerva Villegas (Wellness Coordinator)		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Personal Rights
Facility staff did not provide supervision

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Minerva Villegas (Wellness Coordinator) to deliver findings regarding the complaint allegations above. LPA conducted risk assessment with Wellness coordinator prior to the visit.

During this investigation LPA reviewed records, conducted interviews and made observations at the facility. Reporting party alleged that personal rights were violated. Per reporting party, resident R1 informed them that they had defecated, made a mess on the bed and then went into the bathroom and couldn't get out. The doors in the facility open inward and not outward, so R1 was yelling and banging their head on the door, then care staff came and had an alleged altercation with R1. Resident (R2) heard yelling, called 911 and the police came and transported R1 to the hospital for further evaluation.

Continues on LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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-20210706162313

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: 11/02/2021

NARRATIVE

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Continued from LIC9099…

Based on confidential interviews conducted with residents (R1, R2, R3 and R4), staff (S1, S2, S3, S4, S5 and S6) and records obtained from Napa Police Department, case# NPD2-1002351 dated 9/23/21; R1’s discharge documents provided by facility dated 10/4/21 for incident involving R1 that occurred on 5/29/21 concluded that the event had occurred, but there is no evidence to prove that personal rights were violated at the time of the incident. A finding that the complaint allegation personal rights is unsubstantiated meaning that 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.

Regarding the allegation of facility staff did not provide supervision. Per reporting party, it was alleged that the day of the incident R2 had to call 911 because they don’t have anyway to get the attention of the caregivers in the front and there are concerns about call light system working properly. Based on visits conducted on 9/9/21 and 9/22/21 staff were present and appeared to be sufficient staff to meet resident’s needs. LPA obtained staff schedules for the months of May, June and July 2021 that appears that facility has provided enough staff to meet resident’s needs. However, hourly monitoring sheets provided by facility revealed that on 5/29/21 R1 was not assisted with incontinence care during the timeframe of 6am to 7am of next day. Per R1’s service plan dated 2/8/21 which was not signed by resident or responsible party indicated that R1 will be provided with full assist: “security checks every two hours and as needed”; “R1 requires one bed check per night per safety reasons”. R1 has a diagnosis of Severe Dementia on their physician report dated 10/16/20 that requires full assistance with some ADLs including standby assist while using the bathroom. LPA will address that facility is not following their plan of operation on a case management inspection. LPA confirmed call light system is working. Although there are concerns in response time.

A finding that the complaint allegation facility staff did not provide supervision is unsubstantiated meaning that 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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
07/06/2021 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210706162313

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: 34	DATE:	11/02/2021
		UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Minerva Villegas (Wellness Coordinator)		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility did not report incident timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Wellness coordinator, Minerva Villegas to deliver findings regarding the complaint allegations above.

During investigation LPA reviewed records and conducted interviews at the facility. It was alleged that facility did not report incident timely. On 6/3/21 CCL received a self-incident report describing the incident that occurred on 5/29/21 involving resident (R1) and including responsible parties that were notified at the time of the incident. Incident report logs indicated that incident report was submitted to CCL within seven days as stated on regulations. This agency has investigated the complaint alleging that the “Facility did not report incident timely”. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021

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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