286803790-3-10-2021-21-AS-KMOA-BZFRBU-20210325125318

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286803790
Report Date: 03/08/2021
Date Signed: 03/10/2021 10:28:51 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
11/16/2020 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201116090028

FACILITY NAME:	ROSE HAVEN LLC		FACILITY NUMBER:	286803790
ADMINISTRATOR:	FRANCO, RHON		FACILITY TYPE:	740
ADDRESS:	520 SANITARIUM RD		TELEPHONE:	(707) 963-3748
CITY:	ST HELENA	STATE: CA	ZIP CODE:	94574
CAPACITY:	32	CENSUS: 7	DATE:	03/08/2021
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Rose Mahawar		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident left facility unassisted
Facility does not have adequate staff to meet residents care needs
Facility failed to report resident AWOL

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Angela Elliott made contact this date, by phone, with Rose Mahawar, Manager, for the purpose of delivering findings for above allegations. It is being conducted by phone due to COVID - 19 precautions.

There is an allegation resident left facility unassisted. While on a tele -visit with Rhon Franco, Administrator on 10/30/2020 LPA observed R1 try and leave the facility unassisted and unsupervised. LPA received incident report on 1/12/2021 for incident occurring 1/3/2021 where resident exited facility, fell outside the facility and sustained a head injury. Interview with Administrator on 2/24/2021 indicated a tele communications worker saw that R1 had wandered away from the facility to the street and took R1 to the hospital on 11/10/2021. Rhon indicated he had to go pick up R1 and bring him back to the facility. *** Two Civil Penalties in the amount of $250.00 each are being issued for repeat violations within the last 12 months.
(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: 03/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021

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 3

Control Number 21-AS-20201116090028

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: 03/08/2021

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

Sheriff report documentation dated 12/27/2020 indicates “Elderly Male just showed up” (R1). Information was provided during interview that R1 during 12/27/2020 incident was transported back to facility. LPA conducted tele-visit with Rose Mahawar, Manager to obtain additional information for 12/27/2020 incident due to CCL not receiving incident report. Incident report was received on 3/5/2021. Based on LPAs observations, interviews and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

There is an allegation facility does not have adequate staff to meet residents care needs. On 10/30/2020 LPA contacted facility to conduct tele visit. Administrator was reflected as working on the schedule but when LPA called the facility LPA was told by staff he was asleep. Administrator called LPA and said he was asleep and is on call on Fridays. LPA asked for updated schedules to reflect which staff were actually working. Schedules indicate facility going to one NOC shift staff on 10/28/2020. Interviews revealed and schedules obtained reflect that there is only one caregiver staff on AM shift. Multiples interviews on 2/24/2021 and 3/2/2021 confirmed facility does not have adequate staff to meet resident care needs. Interview with outside party on 3/5/2021 confirmed facility is short-staffed. Addressed in another allegation, R1 AWOL’d from the facility on three different occasions indicating facility does not have sufficient staffing. Based on LPAs observations, interviews and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

There is an allegation facility failed to report resident AWOL. R1 wandered away from the facility on 11/10/2020 and 12/27/2020. Facility did not report to CCL within regulatory time frames. Tele-visit was conducted with Rose Mahawar on 3/5/2021 LPA requested Incident report for 12/27/2020 incident which was received on 3/5/2021. 11/10/2021 incident report was received from Administrator on 2/25/2021. Incident report for 1/3/2021 incident was received by CCL on 1/12/2021. Based on LPA observations, interview and record review the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. 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: 03/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20201116090028

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: 03/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 03/09/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) 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 was not met as evidenced by: Based on LPA observation, interview and	1 2 3 4 5 6 7	Licensee to ensure staff are sufficient in numbers to meet the needs of residents. Licensee agrees to submit updated staffing schedule, showing 24-hour coverage to meet the needs of residents. Updated staffing schedule to be submitted to CCL by POC date of COB 3/9/2021.
	8 9 10 11 12 13 14	record review, facility did not provide supervision resulting in R1 leaving the facility on three occasions. This is an immediate risk to the Health, Safety and Rights of residents in care. ***Civil Penalty of $250.00 is being issued for repeat violation within the last 12 months.	8 9 10 11 12 13 14
Type B 03/22/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements- (a) Each licensee shall furnish..(1) A written report shall be submitted…within seven days…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by: Based on LPA observation, interview	1 2 3 4 5 6 7	Licensee to ensure incidents are reported to CCL according to regulation. Administrator /Manager agrees to train all staff on reporting requirements and submit proof of training by POC due date of 3/22/2021.
	8 9 10 11 12 13 14	and record review incident reports were not sent to CCl within 7 days when R1 AWOL’d from the facility three times. This is a potential risk to the Health, Safety and Personal Rights of residents in care. ***Civil Penalty of $250.00 issued for repeat violation issued within the last 12 months.	8 9 10 11 12 13 14

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: 03/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3