<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 01/18/2024
Date Signed: 01/18/2024 11:58:54 AM

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
01/08/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240108143927
FACILITY NAME:LODGE AT GLEN COVE, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:JASMINE SEIFFERTFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 131DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jasmine SeiffertTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical attention for resident in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation consisted of site visits to facility, taking statements from staff and witnesses, review of pertinent documents. The following determinations are made: Complainant alleges that R1 was exhibiting unusual behaviors on or about 10/23/2023 and that the POA for R1 and the facility staff refused to seek medical care for R1 and that R1 had a dangerously high blood pressure; Staff state that R1 refuted Complainant's claims and had a blood pressure reading that was average for R1; Blood pressure logs confirm staff statements; Chart notes indicates that R1 exhibited "confused" behavior that day which appears to be a pattern of behavior that is documented on other days in the chart; Paramedics were called and R1 was taken to medical facility and released the same day back to the facility; After visit summary report indicates R1 was evaluated for cognitive issues and makes no mention of high blood pressure. Although the allegation may be true, based on statements and documents, there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, it is UNSUBSTANTIATED.
Report left. No citations issued today.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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 2
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
01/08/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240108143927

FACILITY NAME:LODGE AT GLEN COVE, THEFACILITY NUMBER:
486803921
ADMINISTRATOR:JASMINE SEIFFERTFACILITY TYPE:
740
ADDRESS:140 GLEN COVE MARINA ROADTELEPHONE:
(707) 592-1157
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:155CENSUS: 131DATE:
01/18/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jasmine SeiffertTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not insure that resident was adequately fed

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This investigation consisted of site visits to facility, taking statements from staff and witnesses, review of pertinent documents. The following determinations are made: Complainant alleges that on or about 12/28/2024, the facility ran out of food and served R1 a salad for dinner; Facility staff, including the Culinary Services Director state that the facility has never run out of food and that there is an a la carte food service available all day to 7:30 pm for residents who do not want to eat the day’s planed menu; The a la carte menu is extensive and the availability of the items has been verified; R1’s personal representative indicates satisfaction with facility’s food service; Several site visits to facility by staff from this Department in the recent past indicate that facility consistently provides fresh and non perishable food in adequate supply and which meets the required nutritional standards. Based upon interviews and documents, we find the complaint is UNFOUNDED, meaning that it is false and without a reasonable basis. The complaint is DISMISSED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
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 2