486803921-3-10-2025-21-AS-KMOA-DES2N5-20250314173206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 03/10/2025
Date Signed: 03/10/2025 11:08:28 PM

Unsubstantiated

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
10/29/2024 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20241029133104

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: 144	DATE:	03/10/2025
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Jasmine Seiffert, Executive Director/Administrator		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to resident in care resulting in multiple falls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Canela arrived unannounced for the purpose of getting additional information and delivering findings to the above allegation. LPA met with Jasmine Seiffert, Executive Director.

In the course of the investigation LPA reviewed records, made observations and took statements. It was alleged facility staff did not provide adequate supervision to resident in care resulting in multiple falls. LPA reviewed resident R1s file and the following was noted. R1 moved in to the facility on 8/27/2024. R1s facility service plan with R1s husband, identified R1 requiring moderate assistance with bathing, dressing, grooming and no assistance with mobility, transfers to/from bed/chair, meals; full assistance with medication and although identified as independent for mobility, R1 required escort to meals and activities. It was noted on 8/30-8/31/2024 R1 was refusing to eat, agitated and aggressive towards staff, R1s husband went to facility and picked up R1 to stay at home and R1 was then returned to facility on 9/3/2024.

Continue report see LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

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-20241029133104

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: 03/10/2025

NARRATIVE

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After 9/5/2024, R1 was noted to be combative again, with aggressive behaviors and sustained un-witnessed falls, where they were sent to Emergency Department (ER) and returned the same day with a change in medications.
Facility expressed that R1 was in the facility for a short period of time, the first week is always hard for new residents to adjust to their new home. R1 continued to be combative was sent to ER and the medication was adjusted, R1 was then more sleepy, and sustained falls in their room while walking and not when assistance or supervision was required by staff, based on their service plan. on 9/10/2024, R1 was placed on Hospice care with Anchor Health, who placed R1 on comfort meds ordered and increased medication. Facility was following R1s doctors and Hospice orders with medication and medication was keeping resident sleepy. Facility stated they had developed a fall prevention plan as R1s was often drowsy from the medication, and a meeting with R1s family and Physician was being planned, but R1 moved out on 9/18/2024. Staff interviewed expressed R1 was being supervised and did not require 1 to 1 care.
Although the allegations may be true, based on the above information, and records reviewed, there is not a preponderance of evidence to prove or, disprove, the allegation did occur. Therefore, the allegation for staff did not provide adequate supervision to resident in care resulting in multiple falls is UNSUBSTANTIATED at this time.

No citation issued.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

LIC9099 (FAS) - (06/04)

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