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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804073
Report Date: 12/29/2022
Date Signed: 12/29/2022 04:36:20 PM

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
11/17/2022 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20221117100324
FACILITY NAME:SUMMER ROSE SENIOR LIVING LLCFACILITY NUMBER:
486804073
ADMINISTRATOR:FROELICH, RICHARDFACILITY TYPE:
740
ADDRESS:120 HAWKESBURY WAYTELEPHONE:
(707) 515-9099
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 4DATE:
12/29/2022
UNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kristine Bernardino, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff are not adequately trained (First Aid and CPR certified).
INVESTIGATION FINDINGS:
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On 12/29/2022 Licensing Program Analyst (LPA) Tobola conducted an unannounced visit for the purpose of delivering complaint findings and was greeted by Administrator, Kristine Bernardino. LPA conducted a tour of the facility, interviewed staff and reviewed staff training files.

Complaint alleges facility staff are not adequately trained in 1st & Aid and CPR. Based on a review of records LPA found that staff (S1, S2 & S3) had received updated 1st Aid and CPR training on 11/22/2022 (S1 & S2) and 11/23/2022 (S3). However, upon interview with staff and Administrator, Kristine Bernardino no previous current 1st Aid & CPR training were on file or able to be provided prior to the receiving of the complaint 11/17/2022.

Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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 3
Control Number 21-AS-20221117100324
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: SUMMER ROSE SENIOR LIVING LLC
FACILITY NUMBER: 486804073
VISIT DATE: 12/29/2022
NARRATIVE
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Allegation, facility staff are not adequately trained (First Aid and CPR certified) is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20221117100324
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: SUMMER ROSE SENIOR LIVING LLC
FACILITY NUMBER: 486804073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2023
Section Cited
CCR
87411(c)(1)
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87411(c)(1)PERSONNEL REQUIREMENTS GENERAL; Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based
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Facility failed to ensure all staff have current 1st Aid & CPR training on file. As of visit date, Administrator has ensured that staff S1, S2 & S3 have completed their 1st Aid & CPR training and is on file.
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on record review, staff S1, S2 & S3 did not have proof of 1st Aid & CPR training on file prior to the complaint received date 11/17/2022. This serves as a potential health & safety risk to residents in care.
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Administrator understands the regulation and will ensure training is up to date moving forward. Deficiency cleared at the time of visit.
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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: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3