286803790-7-17-2020-21-AS-BMOS-BSDSQU-20200811140520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286803790
Report Date: 07/14/2020
Date Signed: 07/17/2020 08:31:50 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
02/21/2020 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200221093531

FACILITY NAME:	ROSE HAVEN LLC		FACILITY NUMBER:	286803790
ADMINISTRATOR:	WAWERU, PETER		FACILITY TYPE:	740
ADDRESS:	520 SANITARIUM RD		TELEPHONE:	(707) 963-3748
CITY:	ST HELENA	STATE: CA	ZIP CODE:	94574
CAPACITY:	32	CENSUS: 18	DATE:	07/14/2020
		ANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Rhon Franco		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Lack of staff training results in resident skin tears and bruising while being transferred by staff
Food service is inadequate

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via tele-visit, with Administrator, Rhon Franco for the purpose of delivering findings for above allegations. It is being conducted via tele-visit due to COVID - 19 precautions.

This Department has conducted a complaint investigation regarding the above captioned allegation lack of staff training results in resident skin tears and bruising while being transferred by staff. LPA conducted an interview with S1 on 3/20/2020, S1 provided LPA information to support the alleged allegation. S1 indicated staff are not adequately trained before transferring residents. Interview on 5/27/2020 with outside party stated, “Staff are not adequately trained”. Regarding resident injuries, outside party indicated it was reported there is a lack of help in the morning and the staff have improper methods of transfer. In interview conducted on 2/24/2020 with Administrator LPA was provided information of an injury to R1 during care.

Signature on file

(See 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

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 6

Control Number 21-AS-20200221093531

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: ROSE HAVEN LLC	FACILITY NUMBER: 286803790
	VISIT DATE: 07/14/2020

NARRATIVE

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S5 and S2 were changing R1 and S5 said R1 made a noise like they were hurting and R1 got some skin tears on left forearm. (photo obtained). Administrator also indicated R2 sustained a right skin tear on lower leg, happening when S5 and S2 or S6 pulled R2 from the wheelchair to the bed. (Photo obtained). Interview on 2/24/2020 with Administrator described what happened to cause injury to R3. S6 informed they were going into R3’s room to transfer into the bed and accidentally bumped R3’s left hand and scraped the 3rd and 4th knuckle. (Photo obtained).

The following entries were listed in the Facility staff communication book; R1-Skin tear to top of left hand on transfer this AM. (photo obtained). R2…wants staff to be more careful with transfers (photos obtained). R5 Old bruise left elbow area and small bruise L breast area. What happened? (photo obtained).

On 2/24/2020 LPA requested training documentation for fourteen staff. Administrator indicated they did not have access to training documentation and would pass on the request to Manager. LPA requested to review S3’s personnel file. Administrator indicated it was at Managers other facility. LPA was unable to review training records and personnel file during visit. Partial training Documentation from 2018 was received for Administrator, S5, S8, S4 and partial 2019 training documentation for S4. LPA followed up via email to Administrator and Manager on 3/5/2020 and 5/26/2020 to obtain training. As of 7/14/2020 LPA has not received requested training records. Based on LPA observation, interview and review of documentation, the allegation is SUBSTANTIATED. A SUBSTANTIATED finding means the preponderance of evidence standard has been met.

This Department has conducted a complaint investigation regarding the above captioned allegation of food service is inadequate. On 2/18/2020 and 2/24/2020 inadequate sources of perishable and non-perishable foods were observed by LPA (photos obtained). On 3/4/2020 LPA observed inadequate sources of perishable food (photos obtained). LPA interviews conducted with multiple staff provided consistent information to support the above allegation. Interviews revealed that staff were instructed to limit food amounts and re-serve food and beverages that was not finished by residents. LPA was provided information that expired food was being brought into the facility to serve the residents and the quality of food was not good for the residents. Interview with S9 on 6/5/2020 confirmed residents have had oatmeal every morning for the past two months. On 3/24/2020 LPA compared lunch served to menu posted at the facility which did not match. (Photo obtained). S11 confirmed in an interview on 6/11/2020 that the meals served do not match the weekly menu.

Signature on file

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 21-AS-20200221093531

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: ROSE HAVEN LLC	FACILITY NUMBER: 286803790
	VISIT DATE: 07/14/2020

NARRATIVE

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Based on LPA observation, interview and review of documentation, the allegation is SUBSTANTIATED. A SUBSTANTIATED finding means the preponderance of evidence standard has been met.

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.

Signature on File

(See 9099-D)

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 21-AS-20200221093531

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: ROSE HAVEN LLC	FACILITY NUMBER: 286803790
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 07/14/2020 Section Cited CCR 87555(b)(2)(6)	1 2 3 4 5 6 7	87555(b)(2)(6) General Food Service Requirements. Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator/Manager agrees to submit a plan to ensure adequate food supply and service to residents by COB 7/15/2020 and to submit a copy of food purchase receipts beginning the week of 7/20/2020 for a month to CCL by POC due date of 8/20/2020.
	8 9 10 11 12 13 14	Based on observation on 2/18/2020, 2/24/2020 and 3/4/2020. Licensee failed to ensure facility maintained two days’ worth of perishable foods for residents in care. This poses an immediate health, safety or personal rights risk to residents in care.	8 9 10 11 12 13 14
Type B 07/14/2020 Section Cited CCR 87412(g)	1 2 3 4 5 6 7	87412(g) Personnel Records - All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator/Manager to ensure that all current and former employees have a complete personnel file and training records on sight at the facility for CCL review. Administrator/Manager agree to conduct an all staff training for the purpose of resident transfer techniques. Administrator/Manager agree to submit a plan to CCL regarding
	8 9 10 11 12 13 14	Based on interview with Administrator, at the facility on 2/24/2020, Licensee failed to maintain personnel record for S3 and provide training requested for staff which is a potential risk to the health, safety or personal rights to residents in care.	8 9 10 11 12 13 14	how all records will be available for review upon CCL request and proof of staff training for resident transfer techniques by POC date 7/28/2020.

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
02/21/2020 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200221093531

FACILITY NAME:	ROSE HAVEN LLC		FACILITY NUMBER:	286803790
ADMINISTRATOR:	WAWERU, PETER		FACILITY TYPE:	740
ADDRESS:	520 SANITARIUM RD		TELEPHONE:	(707) 963-3748
CITY:	ST HELENA	STATE: CA	ZIP CODE:	94574
CAPACITY:	32	CENSUS: 18	DATE:	07/14/2020
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Rhon Franco		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not assisting with administration of medication.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Elliott made contact this date, via tele-visit, with Administrator, Rhon Franco, for the purpose of delivering findings for above allegation. It is being conducted by tele-visit due to COVID - 19 precautions.

This Department has conducted a complaint investigation regarding the above captioned allegation of staff are not assisting with administration of medication. Complainant alleges medications were observed on the floor and staff do not ensure medications are being taken resulting in residents putting medication in their pockets. LPA made observation on 3/11/2020 meds were given, LPA didn’t observe medications left unsupervised with residents or medication on the floor. Administrator indicated in an interview on 2/24/2020, “Last Thursday I had to face time with staff as they could not find the 8:00 PM meds. During follow-up interview with Administrator on 6/17/2020 Administrator indicated 8:00PM medications were not given for R3, and S3 and S6 were working that evening. Administrator drove to facility to give residents their meds around 10:00PM. Administrator also stated, “Sometimes the PM staff give medications late if the families come around dinner time.” Signature on file.

(See 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 21-AS-20200221093531

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: ROSE HAVEN LLC	FACILITY NUMBER: 286803790
	VISIT DATE: 07/14/2020

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Although the allegations may be true, or are valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. Signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Angela Elliott	TELEPHONE: (470) 717-1668
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

LIC9099 (FAS) - (06/04)

Page: 6 of 6