486803921-8-10-2022-21-AS-KMOA-CHDU3P-20220817151351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 08/09/2022
Date Signed: 08/10/2022 09:05:04 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
04/18/2022 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220418160615

FACILITY NAME:	LODGE AT GLEN COVE, THE		FACILITY NUMBER:	486803921
ADMINISTRATOR:	KINDRED, NICHOLE		FACILITY TYPE:	740
ADDRESS:	140 GLEN COVE MARINA ROAD		TELEPHONE:	(707) 592-1157
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	155	CENSUS: 98	DATE:	08/09/2022
		UNANNOUNCED	TIME BEGAN:	02:03 PM
MET WITH:	Grace Sandoval		TIME COMPLETED:	04:04 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Medication management is inadequate.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings, regarding the above listed allegation. LPA toured the inside of this facility, made observations, and previously gathered statements and obtained records.

It was alleged medication management is inadequate, in that there have been instances when staff do not get the medication right or they do not refill the medication. LPA gathered statements and reviewed records. LPA received corroborating statement from R1 who stated that on 7/14/2022 staff S3 came in to provide medication and informed R1 they were out of one of the medications and could not provide it.

Continue report see LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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-20220418160615

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: 08/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/10/2022 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4): Incidental Medical and Dental Care Services. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility administrator will submit proof of in service medication training and written statement on how they will ensure all staff providing medication are fully trained.
	8 9 10 11 12 13 14	Based on record review, and interview w/Care Coordinator S4 & Administrator. The facility failed to ensure R1's medication was provided as prescribed by doctor when Staff S3 told R1 they were out of medication and could not provide, additional staff located medication an hour and a half later and staff S3 had made a mistake. This poses an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14	POC due date for written statement due, 8//10/2022 and proof of training by 8/19/2022 To LPA A. Canela
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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
04/18/2022 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220418160615

FACILITY NAME:	LODGE AT GLEN COVE, THE		FACILITY NUMBER:	486803921
ADMINISTRATOR:	KINDRED, NICHOLE		FACILITY TYPE:	740
ADDRESS:	140 GLEN COVE MARINA ROAD		TELEPHONE:	(707) 592-1157
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	155	CENSUS:	DATE:	08/09/2022
		UNANNOUNCED	TIME BEGAN:	02:03 PM
MET WITH:	Grace Sandoval		TIME COMPLETED:	04:04 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not meeting resident's needs.
Resident's call button is not answered in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings, regarding the above listed allegations. LPA toured the inside of this facility, made observations, and previously gathered statements and records.
It was alleged Facility is not meeting resident's needs in that resident (R1)dietary needs are not being met or not available. R1's medical assessment documents the need for soft foods. LPA did not receive any corroborating statements from staff or R1. It was also alleged residents call button is not answered in a timely manner. LPA reviewed some call logs and documentation showed most calls are answered under 5 minutes and a few at under 10 minutes. LPA did not receive any corroborating statement from R1 in regards to time it takes for staff to respond.
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 allegations for Facility is not meeting resident's needs.
Resident's call button is not answered in a timely manner. UNSUBSTANTIATED.
No citations issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220418160615

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: 08/09/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 insisted the facility had refilled the medication and should be available. After more than an hour, another med tech located the medication and informed R1 that staff S3 had made a mistake and medication was available.

Based on LPA’s record review & statements received, the preponderance of evidence standard has been met, therefore the allegation for medication management is inadequate 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 provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4