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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804059
Report Date: 04/21/2023
Date Signed: 04/21/2023 01:59:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
09/29/2022 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20220929091847
FACILITY NAME:ARVEAH'S CARE HOMES 3FACILITY NUMBER:
486804059
ADMINISTRATOR:MARTINEZ-DAVIS, LEAHFACILITY TYPE:
740
ADDRESS:2033 MARSHALL ROADTELEPHONE:
(530) 662-6055
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:6CENSUS: 4DATE:
04/21/2023
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Licensee/Administrator, Leah Martinez-DavisTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff neglect caused resident's death.
Staff failed to administer resident's oxygen per physicians orders.
INVESTIGATION FINDINGS:
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Licensing Program Analust Bertozzi arrived unannounced to deliver findings regarding the above mentioned complaint allegations and was greeted by staff. Licensee/Administrator, Leah Martinez-Davis arrived later.

Staff neglect caused resident's death - Complaint alleges that facility turned off resident's oxygen periodically despite resident needing oxygen 24 hours per day causing the resident's death. The Department reviewed the resident's death certificate and other medical documentation and could not confirm whether or not staff neglect caused resident's death.

Staff failed to administer resident's oxygen per physicians orders - Complaint alleges that facility turned off resident's oxygen periodically despite resident having a doctor's order for oxygen 24 hours per day.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
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
Control Number 21-AS-20220929091847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ARVEAH'S CARE HOMES 3
FACILITY NUMBER: 486804059
VISIT DATE: 04/21/2023
NARRATIVE
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Continued from LIC9099

Review of order confirmed that resident was to receive "continuous" oxygen as of 9/16/2023 but prior to that it was on an "as needed" basis. Information received during interviews was conflicting on whether or not the oxygen was turned off. Per Licensee, once the physician's order changed from "as needed" to "continuous", the oxygen machine was not turned off for any reason.

A finding that the complaint allegations, Staff neglect caused resident's death and Staff failed to administer resident's oxygen per physicians orders were unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.

No deficiencies cited.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2