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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804053
Report Date: 06/13/2023
Date Signed: 06/13/2023 11:30:22 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/17/2023 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20230517113253
FACILITY NAME:NAZARETH ROSE GARDEN OF NAPAFACILITY NUMBER:
286804053
ADMINISTRATOR:GOCO, MARISOLFACILITY TYPE:
740
ADDRESS:903 SARATOGA DRIVETELEPHONE:
(510) 468-1909
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:44CENSUS: 20DATE:
06/13/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Joey MendezTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Medication is not being given as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint. LPA met with Res. Care Director and discussed the allegation. During the course of this investigation this Department has interviewed witness and staff; obtained and reviewed documents; made site visits to the facility. Based on these actions, the following determinations are made: Complainant alleges that R1 was not administered prescription eye drops on several occasions while in residence at the facility; The Medication Administration Record for R1 indicates missed doses of eye drops on 3 occasions in April and on 4 occasions in March, 2023; Facility Administration states that the doses were administered but that they were inadvertently not documented on the Medication Administration Record. Based upon the statements taken and the documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and 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. Exit interview conducted and appeal of rights provided. Report left.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
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 2
Control Number 21-AS-20230517113253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NAZARETH ROSE GARDEN OF NAPA
FACILITY NUMBER: 286804053
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2023
Section Cited
CCR
87465(c)(2)
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8746(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. ***Based on documents reviewed and statements made, this requirement has not been met as evidenced by: R1 was not

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Administration has scheduled refresher training for all staff who administer medication to residents on June 22. Administration to submit proof of training to CCL by POC date in order to clear the deficiency.
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administered prescribed eye drops on 3 occasions in April 2023 and on 4 occasions in March of 2023. This posed an immediate risk to the health of R1.
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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023
LIC9099 (FAS) - (06/04)
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