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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 12/15/2022
Date Signed: 12/16/2022 11:32:35 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
07/06/2022 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220706092426
FACILITY NAME:LODGE AT GLEN COVE, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:KINDRED, NICHOLEFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
03:09 PM
MET WITH:Cathy Villareal, Marketing DirectorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Untrained staff assisting residents
Facility is not following covid procedures
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings regarding the above listed allegations. LPA previously conducted inspections, toured the inside of this facility, made observations, requested records and gathered statements.

It was alleged untrained staff are assisting residents. LPA received corroborating statements from staff S1 who stated staff S2 had not received or completed all of their medication training prior to assisting resident R1 with medication. It was also alleged facility is not following covid procedures and visitors were coming in with no proof of vaccinations, a negative covid test, taking temperatures or hand sanitizing upon entrance; more specifically during the weekends.
LPA received corroborating statements from visitors and 1 staff that visitors were just coming in and there were no staff in the front area. One visitor who was not vaccinated came in and was not asked to provide proof of a negative Covid-19 test back in July 2022, when this was still a requirement.
LPA also observed that when there is other staff covering the front area, other then the main front staff, visitors came in without getting their temperatures checked or hand sanitizing upon entrance to this facility to ensure hand hygiene and Covid-19 protocols.
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: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
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 4
Control Number 21-AS-20220706092426
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: 12/15/2022
NARRATIVE
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 Based on LPA’s record review & statements received, the preponderance of evidence standard has been met, therefore both allegations for Untrained staff assisting residents and Facility is not following covid procedures are 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: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20220706092426
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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by: Based on LPA’s observations, the Licensee did not comply with
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Facility to submit a written plan to CCL on how they will ensure that COVID procedures will be followed by 12/16/2022 and facility to provide In-service Training stating that Facility has read and understood COVID procedures based on current Public Health and Social Services Departmental guidelines.
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the Department of Public Health and Department of Social Services Guidelines and Requirements related to COVID-19. LPA received corroborating ionformation some visitors are not all screened mainly on the weekends or are not hand santizing an being screened for COVID related symptoms. This poses an immediate health and safety risk to residents in care.
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written plan POC due date 12/16/2022 and proof of training POC due date 12/26/2022 Attention LPA Araceli Canela
Type B
12/23/2022
Section Cited
CCR
874119(d)
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874119(d)Personnel Requirements - General(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
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Facility to to send in written plan they understand requirements and how they will ensure it is being met.

POC due date 12/23/2022 to LPA Araceli Canela
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This requirement was not met as evidenced by: Investigation and corroborating statement showed, staff S2 did not have all the required training. This is a potential risk to the health and 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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 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
07/06/2022 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220706092426

FACILITY NAME:LODGE AT GLEN COVE, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:KINDRED, NICHOLEFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: DATE:
12/15/2022
UNANNOUNCEDTIME BEGAN:
03:09 PM
MET WITH:Cathy Villareal, Marketing DirectorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Insufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings regarding the above listed allegations. LPA previously conducted inspections, toured the inside of this facility, made observations, requested records and gathered statements.

It was alleged the facility has insufficient staffing. LPA gathered statements and received conflicting statements that there is enough staff, can use more staff and that there is no issue with staffing. Facility Administrator expressed, they have had some problems with hiring but they have enough staff and have hired some from outside agency. LPA reviewed time sheets and time sheets showed staffing on all shifts. 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 allegation for insufficient staffing is UNSUBSTANTIATED.
No citations issued.
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: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4