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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 10/14/2021
Date Signed: 10/21/2021 09:53:58 AM



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 Araceli Canela
COMPLAINT CONTROL NUMBER: 21-AS-20210830132758
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: 83DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Nichole KindredTIME COMPLETED:
04:14 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), A. Canela arrived unannounced
on 10/14/202, for the purpose of gathering additional information and delivering findings to the allegation listed above. LPA met with Administrator, Nichole Kindred.

LPA obtained and reviewed additional records, conducted interviews, toured memory care unit and spent time making observation. It was alleged staff did not safeguard resident's personal items, such as an electric shaver that was purchased on 4/24/21 for resident R1. LPA received corroborating statements and records showing R1s electrical shaver was missing and the facility, reimbursed R1's family $70.00 for the replacement of the missing shaver. Administrator explained they believed R1's private assistant would assist R1 with shaving needs and may have the shaver, but facility decided to just reimburse the resident.

continue report on LIC9099-C
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: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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
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 Araceli Canela
COMPLAINT CONTROL NUMBER: 21-AS-20210830132758

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: 83DATE:
10/14/2021
UNANNOUNCEDTIME BEGAN:
12:13 PM
MET WITH:Nichole KindredTIME COMPLETED:
04:14 PM
ALLEGATION(S):
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Resident sustained unexplained weight loss
Staff did not assist resident with its hygiene care needs
Staff did not provide appropriate meals to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), A. Canela arrived unannounced
on 10/14/202, for the purpose of gathering additional information and delivering findings. LPA met with Administrator, Nichole Kindred.

LPA obtained and reviewed additional records, conducted interviews, toured memory care unit and spent time making observations. A complaint was received to report resident R1 had unexplained weight loss; staff did not assist with hygiene needs and appropriate meals were not provided. It was alleged R1 had rapid weight loss, was not provided enough food and R1's appearance was unkempt and could never tell if R1 had received a shower. LPA received information from facility, that R1 appeared to have the same weight or may have lost just a few pounds. R1 did not refuse meals and received 2 showers a week. R1 was not on any special diet and was provided the food items that were on the menu. Reporting party was unable to provide LPA with weight loss amount or R1's current weight. LPA did not receive pictures or any additional information to corroborate the above allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited for the above allegations.
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: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20210830132758
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: LODGE AT GLEN COVE, THE
FACILITY NUMBER: 486803921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/30/2021
Section Cited
CCR
87217(b)
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87217(b)Safeguards for Resident Cash, Personal Property, and Valuables.(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.
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Facility to send in written plan. By POC due date 10/30/2021
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This requirement was not met as evidenced by: Investigation revealed R1's electric shaver was reimbursed to R1 after facility could not locate. This is a potential 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20210830132758
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: LODGE AT GLEN COVE, THE
FACILITY NUMBER: 486803921
VISIT DATE: 10/14/2021
NARRATIVE
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 Based on LPA’s record review & statements received, the preponderance of evidence standard has been met, therefore the allegation for staff did not safeguard resident's personal items is 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 and this report will be emailed to facility due to printer problems.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4