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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803786
Report Date: 02/10/2023
Date Signed: 02/13/2023 12:41:31 PM

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
02/03/2023 and conducted by Evaluator Araceli Canela
COMPLAINT CONTROL NUMBER: 21-AS-20230203105830
FACILITY NAME:ISLES ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
486803786
ADMINISTRATOR:EFE, ELENAFACILITY TYPE:
740
ADDRESS:129 PACER DRTELEPHONE:
(707) 254-5444
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Suzzete TawzerTIME COMPLETED:
04:03 PM
ALLEGATION(S):
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Facility does not have not have a proper system for residents to alert staff for assistance.
Facility staff left resident in soiled bedding for an extended period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced for the purposes of opening the above investigation for complaint number 21-AS-20230203105830. LPA toured the facility, made observations and took statements. The Administrator, Suzette Tawzer arrived a few minutes later.

It was alleged Facility does not have not have a proper system for residents to alert staff for assistance. LPA A Canela conducted a walk through and observed 2 resident bedrooms(R1, R2)with no bells or alert system and 1 resident bedroom(R3) with a bell that was broken and non operational. This facility has long hallways and staff bedrooms are on the front side of the facility and residents who may need assistance at night require a way to properly alert staff for help.

See continuation of report LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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 4
Control Number 21-AS-20230203105830
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
VISIT DATE: 02/10/2023
NARRATIVE
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It was also alleged facility staff left resident in soiled bedding for an extended period of time. Investigation revealed resident R1 was not able to get assistance at night. It was corroborated, staff respond during the day, when residents call for assistance, but when the bell is used at night, staff cannot hear and do not respond. In addition R1 did not have a bell. It was disclosed to LPA resident R1, called for assistance to use the bathroom/potty chair and staff did not respond. R1's physician report states R1 needs assistance out of bed as they are at fall risk. R1 stated they slipped to the floor, urinated and then grabbed blanket to cover themselves as it was cold and remained on the floor in a soiled floor/blanket until the morning when staff found R1. There was no indication of the exact time R1 was left without assistance as they were not able to communicate with staff. LPA received contradicting statements from staff who stated, R1 was found hiding on the floor, was not urinated but had heard/seen R1 throwing up. Staff later disclosed, they found R1 with throw up sitting on the floor at 4 am. Staff also stated R1 was not there long and had probably just threw up, yet staff disclosed to LPA they last saw R1 at 1am and then saw R1 again around 4am.

Based on LPA’s record review, statements received, and contradicting statements from staff, the preponderance of evidence standard has been met, therefore, allegations for, "facility does not have not have a proper system for residents to alert staff for assistance and
facility staff left resident in soiled bedding for an extended period of time; are both found to be 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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, 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
02/03/2023 and conducted by Evaluator Araceli Canela
COMPLAINT CONTROL NUMBER: 21-AS-20230203105830

FACILITY NAME:ISLES ASSISTED LIVING FACILITY, THEFACILITY NUMBER:
486803786
ADMINISTRATOR:EFE, ELENAFACILITY TYPE:
740
ADDRESS:129 PACER DRTELEPHONE:
(707) 254-5444
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
02/10/2023
UNANNOUNCEDTIME BEGAN:
12:17 PM
MET WITH:Suzzete TawzlerTIME COMPLETED:
04:03 PM
ALLEGATION(S):
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Facility staff did not ensure that resident's bedding was properly cleaned.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Araceli Canela arrived unannounced for the purposes of opening the above investigation for complaint number 21-AS-20230203105830. LPA toured the facility, made observations and took statements. The Administrator, Suzette Tawzer arrived a few minutes later.
It was also alleged facility staff did not ensure that resident's bedding was properly cleaned. LPA received information their blanket still smelled like urine after R1 had an accident. Staff expressed the blanket was washed because R1 had thrown up. Staff stated the residents other blanket came in smelling like urine from home and deny resident R1 urinated on it at the facility. Although the allegations may be true, or are valid, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations for Facility staff did not ensure that resident's bedding was properly cleaned is UNSUBSTANTIATED.
No citations issued regarding the above allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
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
Control Number 21-AS-20230203105830
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: ISLES ASSISTED LIVING FACILITY, THE
FACILITY NUMBER: 486803786
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/13/2023
Section Cited
CCR
87464(a)(d)
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87464 Basic Services (a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care.......
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Facility to send in a written statement they understand regulation, and proof of staff training.
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(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: R1 was left in soiled clothing when they did not receive assistance at night to use the bathroom This is an immediate risk to residents in care
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POC due date 2/13/3023
Attention LPA A CanelaPP
Type B
02/17/2023
Section Cited
CCR
87303(i)(2)
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87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria:(2) Facilities having more than one wing, floor......provided each meets the above criteria.
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Facility to send in written plan on how they will ensure they follow regulation and proof of staff training.
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This requirement was not met as evidenced by:
This facility is L shape with long hall way. Residents require a signal system to alert staff for assistance. R1, R2 and R3 do not have a working bell or system. This is a potential risk to the Health & Safety of residents 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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4