<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804025
Report Date: 08/11/2025
Date Signed: 08/11/2025 12:58:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/11/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250411091753
FACILITY NAME:ZEALCARE HOMEFACILITY NUMBER:
286804025
ADMINISTRATOR:MARTINEZ, MADONNA GRACEFACILITY TYPE:
740
ADDRESS:2504 REDWOOD RD.TELEPHONE:
(707) 258-9348
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:6CENSUS: 0DATE:
08/11/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Madonna Grace Martinez, Administrator/LicenseeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff caused injuries to a resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/11/2025, Licensing Program Analyst (LPA) Julie Florio met with Madonna Grace Martinez, Administrator/Licensee in the Santa Rosa Regional Office to deliver complaint 21-AS-20250411091753 investigation findings regarding the above allegations. Reporting Party (RP) alleges that facility staff caused injuries to a resident while in care.

LPA Florio conducted a 10-day complaint investigation visit on 04/16/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through records review of Hospice pre-admission “suggested orders” for Resident 1 (R1) that a hospital bed with half rails was listed as an approved item for R1. During this visit, LPA observed R1’s hospital bed equipped with full bedrails (see photos). Facility was unable to produce orders for full bed rails. A citation is being issued on a LIC809 - case management/office visit report dated 08/11/2025.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
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-20250411091753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ZEALCARE HOME
FACILITY NUMBER: 286804025
VISIT DATE: 08/11/2025
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
Continued from LIC9099...

Based on an interview with Administrator/Licensee it was revealed that staff 1 (S1) changed R1 and put the rails up to step away to throw the garbage away from the changing R1 when S1 heard a thump. Additionally, based on an incident report dated 10/11/2024 and received by the Department on 10/16/2024, It was revealed that S1 also stepped away to answer the front door to the facility during the time when the thump was heard by S1. LPA attempted to contact S1 on 04/16/2025, 07/30/2025, and 08/08/2025 but was unsuccessful. Per interview conducted with R1’s responsible party, R1’s husband ordered the hospital bed, which came with full bed rails, prior to the 10/11/2024 incident. LPA spoke with the Hospice Nurse on 08/08/2025 and received emailed transcribed notes from R1’s Hospice file which state that R1 was admitted to Hospice services on 10/13/2024 and a Hospice nurse reported observing the bed rails broken. Additionally, the Hospice notes indicate that R1’s family refused the Hospice ordered bed with half rails. Based on an interview with Staff 2 (S2) on 08/08/2025, facility staff are trained to prepare briefs and items for incontinent care prior performing incontinent care, stay with the resident until done, reposition the resident on their back and put the bedrails up before walking away. Based on further record review, it was revealed on R1’s hospital discharge summary dated 10/13/2024 that as the result of this above-mentioned fall on 10/11/2024, R1 sustained a right nasal bone fracture, a frontal scalp hematoma, bruising of the central forehead, and a small superficial abrasion to the inner left nare. Subsequently, on 04/11/2025, the Department received said complaint #21-AS-20250411091753 which indicated that R1 sustained a second injury on 04/06/2025. During the course of an interview with Administrator/Licensee, it was revealed that while performing incontinent care, S1 rolled R1 resulting in R1’s head coming in contact with the bedside table causing injury and bruising to R1’s upper right eye area as captured in photos taken by LPA on 04/16/2025, (see LIC9099D). An immediate civil penalty in the amount of $500 if being issued during today's visit, (see LIC421IM). Based on a death report received by the Department on 05/15/2025, R1 passed away on 05/07/2025 on Hospice care.

Based on interviews conducted and records obtained, the allegation that the facility Staff caused injuries to a resident while in care is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Continued on LIC9099C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20250411091753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ZEALCARE HOME
FACILITY NUMBER: 286804025
VISIT DATE: 08/11/2025
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
Continued from LIC9099C...

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250411091753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ZEALCARE HOME
FACILITY NUMBER: 286804025
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2025
Section Cited
HSC
1569.269(a)(6)
1
2
3
4
5
6
7
§1569.269 Enumerated rights; severability (a)(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on file review,
1
2
3
4
5
6
7
residents in care.

Licensee agrees to submit a self-certifaction that they understand regulation 1569.269 as it pertains to the care and safety of residents to CCL by POC due date of 08/12/2025.
8
9
10
11
12
13
14
interviews conducted and record review, the licensee did not ensure that facility was staffed sufficiently or that staff were competently trained to ensure injuries were not caused to R1 during their care, which poses a health, safety, and/or personal rights violation to
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4