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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803859
Report Date: 12/17/2021
Date Signed: 12/23/2021 11:35:01 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, 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
08/30/2021 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20210830092637
FACILITY NAME:CAREWELL AT RED PHEASANT, LLCFACILITY NUMBER:
486803859
ADMINISTRATOR:COLEMAN, MARIEFACILITY TYPE:
740
ADDRESS:219 RED PHEASANT DRTELEPHONE:
(707) 592-4004
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 4DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ron Adriano, AdministratorTIME COMPLETED:
04:21 PM
ALLEGATION(S):
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9
Staff not providing medications as prescribed
INVESTIGATION FINDINGS:
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LPAs Licensing Program Analyst (LPA) Nakagawa conducted a complaint investigation and met with Administrator Ron Adriano,regarding the allegation: staff are not providing medications as prescribed.
LPA conducted a tour of the facility, interviewed staff, requested medication records and did a physical inspection of medications. R1 was prescribed 315 mg-5 mcg pills but was being given 600 mg tablets without written authorization of physician for the change.
Based on the LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiency is cited from the California Code of Regulations (CCRs), (Title 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights were given.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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 4
Control Number 21-AS-20210830092637
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: CAREWELL AT RED PHEASANT, LLC
FACILITY NUMBER: 486803859
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited
CCR
87465(e)(2)
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7
(e)For every prescription...for which the licensee provides assistance...a signed dated written order from the physician....and a label on the medication. Both the physician's order and the label shall contain...following information.
(2) The exact dosage.
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Staff will be re-trained on medication protocols, regulations and management. Licensee will submit a list of all staff names upon completion to LPA by 12/25/2021.
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This regulation was not met as evidence by**

Based on interview and a review of facility medication administration records it was determined Licensee did not administer the exact dosage of medication as prescribed.
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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: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
08/30/2021 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20210830092637

FACILITY NAME:CAREWELL AT RED PHEASANT, LLCFACILITY NUMBER:
486803859
ADMINISTRATOR:COLEMAN, MARIEFACILITY TYPE:
740
ADDRESS:219 RED PHEASANT DRTELEPHONE:
(707) 592-4004
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 4DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Ron AdrianoTIME COMPLETED:
04:21 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Neglect/lack of staffing resulted in a resident falling from their wheelchair.
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst Jill Nakagawa met with Ron Adriano, regarding complaint.

LPA Nakagawa conducted an investigation and found through interviews, record review, and administration checking camera footage there was no information leading to the conclusion that R1 had a fall during the time frame in question.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20210830092637
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: CAREWELL AT RED PHEASANT, LLC
FACILITY NUMBER: 486803859
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/17/2021
Section Cited
CCR
87465(e)(2)
1
2
3
4
5
6
7
(e) For every prescription...for which the licensee provides assistance...a signed, dated written order from the physician...and a label on the medication. Both the physician's order and the label shall contain...following information:
(2) The exact dosage.This regulation was not met as evidenced by**
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7
Licensee agrees to conduct additional medication training and submit training records to CCL by POC 12/25/2021.
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Based on interview and a review of facility medication records Licensee failed to ensure residents are given the exact dosage of medication prescribed by doctor which poses and immediate health and safety risk to 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4