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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803786
Report Date: 01/22/2021
Date Signed: 01/26/2021 08:56:02 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
03/30/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200330111524
FACILITY NAME:ISLES ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
486803786
ADMINISTRATOR:EFE, ELENAFACILITY TYPE:
740
ADDRESS:129 PACER DRTELEPHONE:
(707) 254-4444
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
01/22/2021
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Suzette TawzerTIME COMPLETED:
05:39 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident eloping.
Facility failed to issue residents a copy of the care plan.


INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) A. Canela contacted Suzette Tawzer, Administrator at The Isles Assisted Living Facility by telephone on 1/22/2021 for the purpose of delivering findings on complaint investigation 21-AS-20200330111524. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

LPA received statements and gathered records. It was alleged facility staff did not provide adequate supervision resulting in resident eloping. Investigation revealed, resident R1 eloped from the facility on 3/25/2020, and staff was unaware when R1 went out. The facility has been previously cited for not having their auditory alarms on, to notify them and alert them when a door is opened to prevent any resident from leaving the facility. It was also alleged the facility failed to issue the resident R1 and responsible party a copy of the care plan.

Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
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 5
Control Number 21-AS-20200330111524
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
VISIT DATE: 01/22/2021
NARRATIVE
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Facility administrator S1 informed LPA she did not provide a copy as she was unaware one was to be provided.
Based on the information received, the preponderance of evidence standard has been met, therefore both allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099-D. Appeal Rights were provided and signature on this report acknowledges receipt. A civil Penalty for $500.00 is being applied for Absence of Supervision.

This report was emailed to facility to obtain signature.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20200330111524
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on review of incident report & interview w/ Administrator, this requirement has not been met as evidenced by:
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Facility to send in written plan regarding reg. 87411(a) that will be followed.
POC Due date 1/26/2021
to LPA A. Canela
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facility failed to ensure R1 was properly supervised, staff was not aware R1 had left the facility and for how long.This is an immediate risk to the health and safety of residents in care. A civil Penalty for $500.00 is being applied for Absence of Supervision.
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20200330111524
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/01/2021
Section Cited
CCR
87467(a)(1)
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87467(a)(1) Resident Participation in Decisionmaking-(a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, resident’s representative... (1) At a minimum the written record shall include the date
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Facility to send in written plan, they understand regulation.
POC due date 2/1/2021 to LPA A. Canela
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 of the meeting, name of individuals who participated and their relationship to the resident, & the agreed-upon services to be provided to the resident. This requirement was not me. Facility did not provide. This is potetial risk to the clients in care
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
03/30/2020 and conducted by Evaluator Araceli Canela
COMPLAINT CONTROL NUMBER: 21-AS-20200330111524

FACILITY NAME:ISLES ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
486803786
ADMINISTRATOR:EFE, ELENAFACILITY TYPE:
740
ADDRESS:129 PACER DRTELEPHONE:
(707) 254-4444
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
01/22/2021
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Suzette TawzerTIME COMPLETED:
05:39 PM
ALLEGATION(S):
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Facility failed to issue residents a copy of the contract
Resident has been left in soiled diapers.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) A. Canela contacted Suzette Tawzer, Administrator at The Isles Assisted Living Facility by telephone on 1/22/2021 for the purpose of delivering findings on a complaint investigation 21-AS-20200330111524. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.
LPA received statements and gathered records. It was alleged facility failed to issue residents a copy of the contract. Facility administrator stated a copy of the contract was provided to R1's responsible party after it was signed. LPA was unable to get any additional information to corroborate the allegation. It was also alleged resident has been left in soiled diapers. Facility denies the allegation and explain, residents are always assisted. LPA previously conducted physical visits and R1's room was very clean and free of odors, LPA did not observe client to have soiled garments. LPA did not get any additional information to verify the allegation. The Department has investigated the above allegations and determined, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are Unsubstantiated.
This report was emailed to facility to obtain signature.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5