286803790-10-30-2020-21-AS-BMOS-BWYR38-20210105113930

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286803790
Report Date: 10/30/2020
Date Signed: 10/30/2020 07:46:59 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
03/02/2020 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200302105626

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: 15	DATE:	10/30/2020
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Rhon Franco		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff lack training to meet resident needs
Staff are sleeping in common area
Facility does not have enough staff to meet resident needs

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.

There is an allegation staff lack training to meet resident needs. LPA followed up with Administrator Rhon Franco, and Manager Rose Mahawar regarding repeated requests for training documentation requested on 4/21/2020 and 5/26/2020. Another request was made on 6/9/2020. Current training documentation that was requested has not been made available to LPA as of this date. 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.Deficiency cited for lack of training documentation complaint control number 21-AS-20200221093531.

(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: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

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 4

Control Number 21-AS-20200302105626

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: 10/30/2020

NARRATIVE

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There is an allegation staff are sleeping in common area. LPA obtained information during this investigation that staff were sleeping in the common area (photos obtained). Based on LPA's observations and interviews which were conducted and document review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

There is an allegation facility does not have enough staff to meet resident needs. On 2/18/2020, 3/8/2020, 3/10/2020, 3/20/2020, 5/14/2020, 5/27/2020 LPA obtained seven staff interviews which revealed concluding information that the facility doesn’t have enough staff to meet resident’s needs. LPA obtained information that cook, housekeeper and volunteer were called upon to assist with resident care needs. On LPA’s visit, when touring with the Administrator, Rhon Franco, LPA observed R2 undressed/unsupervised and not being assisted due to staff being pulled away to assist other residents. Based on LPA review of staffing schedules and resident care need documentation, it was confirmed facility does not have enough staff to meet the care needs of the residents. 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.

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.

(See 9099-D)

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: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20200302105626

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: 10/30/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/30/2020 Section Cited HSC 1569.269(a)	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	POC Manager/Administrator to ensure that client rights are not violated by any staff at any time. Manager/Administrator agrees provide training to staff regarding resident "Personal Rights". Manager/Administrator to submit date for training no later than COB 11/2/2020, and proof staff training with written plan of ensuring
	8 9 10 11 12 13 14	Based on LPA observation, interview and record review the facility did not ensure client's personal rights were not violated. This is an immediate risk to the health, safety, and personal rights of the residents in care.	8 9 10 11 12 13 14	facility's future compliance with this regulation by POC due date of 11/13/2020.
Type A 10/30/2020 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	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 is not met as evidenced by:	1 2 3 4 5 6 7	POC 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 11/2/2020.
	8 9 10 11 12 13 14	Based on LPA record review, observations and interviews conducted, Licensee did not ensure sufficient staff were present to meet the care needs of residents. There are several residents requiring assistance, and at times 2 caregivers working a shift at the facility. This poses an Immediate Health and Safety risk to residents in care.	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: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
03/02/2020 and conducted by Evaluator Angela Elliott

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200302105626

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: 15	DATE:	10/30/2020
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Rhon Franco		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff are not following Dr. orders

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.

There is an allegation staff are not following Dr. orders. On 3/4/2020 LPA and LPM observed R1 sitting on the porch. Record review for R1 indicated R1 needed assistance with ted hose. Outside party indicated R1 had physician’s order for ted hose. LPA and LPM did not observe R1 wearing ted hose (photo obtained). LPA requested physician’s orders for R1 from facility and physician’s orders for compression garment was not sent to LPA. LPA obtained additional information from complainant that the physician’s order was not sent to the facility from the previous facility upon admission. LPA confirmed physician order has been provided to facility. 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.

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: 10/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020

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 4