286803790-4-16-2021-21-AS-KMOA-C2KMAJ-20210430092623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286803790
Report Date: 04/15/2021
Date Signed: 04/16/2021 03:03:23 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
11/12/2020 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201112125529

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: 8	DATE:	04/15/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Rose Mahawar		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility failed to provide follow-up care for resident's injuries after release from hospital.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) A. Canela contacted Rose Mahawar, Manager of Rose Haven, LLC by telephone on 4/15/2021 for the purpose of delivering findings on complaint investigation 21-AS-20201112125529. Due to COVID – 19 precautions a facility in person visit is not able to be conducted at this time.

It was alleged facility failed to provide follow-up care for resident's injuries after release from hospital. R1 sustained a fall on 10/28/2020, while being sheltered at Oakwood Memory & Senior Care due to the Fires. R1 was sent to Sutter Hospital and released back, no fractures noted.
Reporting party alleged, discharge papers from the hospital indicated to apply ice compression, elevate the swollen regions and for R1 to take pain medications/anti-inflammatories to help reduce pain and swelling.
During the investigation, LPA reviewed/obtained records and conducted interviews with facility staff.

Continue report see LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

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-20201112125529

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: 04/15/2021

NARRATIVE

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LPA was unable to obtain a statement or records from complainant due to complainant not returning voicemail messages left on 11/20, 11/23/2020 and 3/3/2021. R1 moved out of the facility on 11/5/2020 and LPA was unable to get a statement from R1. Facility deny the allegation and state R1 was independent, and facility staff assisted R1. Facility disclosed R1's family requested for facility to accept and provide part-time care, 1-2 weeks with family and the other 1-2 weeks at the facility. Facility stated, that on 11/11/2020, R1's family threatened to file a complaint since the facility did not agree to part-time care. Facility states they explained, it would be very difficult to do or provide part-time care for R1, charge by the week, follow program plan and licensing guidelines. LPA did not receive any corroborating statements, that facility staff failed to provide follow-up care for resident's injuries after release from hospital.

The Department has investigated the above allegations and at this time determined, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is Unsubstantiated.

No citations issued for this allegation. This report was emailed to facility to obtain signature.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2021

LIC9099 (FAS) - (06/04)

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