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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803841
Report Date: 07/07/2022
Date Signed: 07/07/2022 05:17:00 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
03/16/2022 and conducted by Evaluator Karina Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220316111542
FACILITY NAME:MEADOWLARK MANORFACILITY NUMBER:
486803841
ADMINISTRATOR:FERNANDEZ, MARIETTAFACILITY TYPE:
735
ADDRESS:1467 MEADOWLARK DRTELEPHONE:
(415) 939-4491
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:4CENSUS: 4DATE:
07/07/2022
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Marie Fernandez, backup Administrator TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff member violated resident's personal rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Canela arrived unannounced to deliver complaint #21-AS-20220316111542 at Meadowlark Manor on 07/07/2022. LPA met with Marie Fernandez, Administrator.

LPA investigated the above allegation of "Staff member violated resident's personal rights". During the investigation, LPA requested and obtained copies of facility documents, conducted interviews, and made observations.
Report continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
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 3
Control Number 21-AS-20220316111542
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: MEADOWLARK MANOR
FACILITY NUMBER: 486803841
VISIT DATE: 07/07/2022
NARRATIVE
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 The following was reported to Community Care Licensing (CCL), Santa Rosa Regional Office:
Client (C1) was admitted to the hospital on 03/03/2022 due to stomach issues. On 03/15/2022 a Meadowlark Manor staff member (S1) arrived to pick up C1, was overheard and observed speaking to a male (believed to be another staff member) on the phone. It was alleged S1 made a comment that they miss the smell of C1's genitals to a staff member over the phone. S1 used a nick-name for C1's genitals. Staff interviews indicated S1 was speaking to their marital partner over the phone, not another staff member when S1 made the comment about C1.
Staff interviews conducted and written statements received revealed S1 & S2 have made comments about missing the smell of C1's genitals or the way C1's genitals smell, on multiple occasions. Staff interviews indicated S1 & S2 were "joking around". Additionally, Meadowlark Manor did not report this incident to CCL initially, LPA received a copy of the report on 03/21/2022 after opening the complaint and questioning if the facility has reported. The facility reported to North Bay Regional Center with an incident report. Administrator stated S1 resigned on 03/29/2022.

Based on observations, records reviewed, and interviews conducted, the licensee did not ensure clients personal rights to dignity and respect between staff and clients due to Staff member who violated resident's personal rights. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Appeal Rights Provided.


Deficiencies cited (see LIC9099-D page) 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 with Marie Fernandez, Administrator whose signature below confirms receipt of report.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20220316111542
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: MEADOWLARK MANOR
FACILITY NUMBER: 486803841
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/20/2022
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights: (a)…each client shall have personal rights which include,... (1) To be accorded dignity in his/her personal relationships with staff and other persons.
**This requirement was not met as evidenced by:
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Administrator to have all staff trained on client's personal rights of regulation 80072 and submit a statement that staff understand they shall not make inappropriate comments/jokes about clients. Statement and staff training (date, time, duration, attendees & their signatures) to be submited to CCL by POC due date 7/20/22
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Based on record review, interviews conducted and observations, licensee did not ensure the regulation above due to staff (S1 & S2) who violated C1's personal rights by making an inappropriate comment about the smell of C1's genitals. This is a potential personal rights risk to 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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3