486803921-10-2-2024-21-AS-KMOA-D9NSY7-20241002141705

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 09/27/2024
Date Signed: 10/02/2024 11:53:59 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
05/02/2024 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240502095016

FACILITY NAME:	LODGE AT GLEN COVE, THE		FACILITY NUMBER:	486803921
ADMINISTRATOR:	JASMINE SEIFFERT		FACILITY TYPE:	740
ADDRESS:	140 GLEN COVE MARINA ROAD		TELEPHONE:	(707) 653-4728
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	155	CENSUS: 139	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Jasmine Seiffert, Executive Director/ Administrator		TIME COMPLETED:	04:52 PM

ALLEGATION(S):

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Neglect/lack of supervision resulting in resident's care needs not being met
Facility not kept clean and sanitary

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of continuing investigation and delivering findings to the above allegations and met with Jasmine Seiffert, Executive Director. In the course of the investigation, LPA toured facility, some resident bedrooms; obtained documents, and took statements.

It was alleged Neglect/lack of supervision resulting in resident's care needs not being met and facility not kept clean and sanitary. More specifically, it was reported that R1 was found with feces all over foot & shoe; bathroom and bedding was soaked in urine.

On a previous visit LPA observed resident (R1) bedroom had a very strong urine odor, the carpet had several large stains and R1's bathroom wall had a tiny smear of feces.

Continue report see LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240502095016

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: LODGE AT GLEN COVE, THE	FACILITY NUMBER: 486803921
	VISIT DATE: 09/27/2024

NARRATIVE

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Continued report from LIC9099

LPA received additional corroborating statements that R1 was found with soiled, soaked in urine clothing, feces on their body and dried feces on the carpet and on bathroom. LPA toured R1s room and R1 had moved out a little over a week and the room did not have any furniture, but the room had a very strong urine smell, the carpet was with larger stains and the bathroom toilet seat and rim had dried smeared feces. It was also corroborated that R1 was found soaked and dirty multiple times and R1s family would pick up clothing to wash. R1s family reported they moved resident out because of the lack of care. LPA was unable to get statements from R1 due to their Dementia diagnoses.

Based on LPA observations and statement received, facility failed to ensure R1s was kept clean and dry and failed to meet R1's needs. Facility also failed to ensure R1s room was clean and sanitary. The preponderance of evidence standard has been met, therefore the allegations for Neglect/lack of supervision resulting in resident's care needs not being met and Facility not kept clean and sanitary 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.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240502095016

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: LODGE AT GLEN COVE, THE	FACILITY NUMBER: 486803921
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/30/2024 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464(d) Basic Services: 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...This	1 2 3 4 5 6 7	Facility agrees to send in written statement on how they will meet regulation and proof of staff training in Memory care unit. Written statement due 9/30/2024
	8 9 10 11 12 13 14	requirement is not met as evidenced by: Based on LPAs observations, interviews conducted and pictures received. Staff did not ensure resident R1 was clean and dry and did not meet their needs. This poses an immediate Health, Safety or Personal rights risk to residents.	8 9 10 11 12 13 14	and proof of staff training focusing on incontinent needs by 10/4/2024 Attention LPA Canela
Type B 10/11/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Facility to send in written plan on how they will stay in compliance and proof of staff training.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Facility failed to keep R1s bedroom clean, and odor free. This is a potential risk to resident in care.	8 9 10 11 12 13 14	POC due date 10/11/2024 attention LPA A Canela

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: Araceli Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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