486804073-11-22-2022-21-AS-KMOA-CNGMYV-20230127090206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804073
Report Date: 11/22/2022
Date Signed: 11/22/2022 04:18:17 PM

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
10/21/2022 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20221021094048

FACILITY NAME:	SUMMER ROSE SENIOR LIVING LLC		FACILITY NUMBER:	486804073
ADMINISTRATOR:	FROELICH, RICHARD		FACILITY TYPE:	740
ADDRESS:	120 HAWKESBURY WAY		TELEPHONE:	(707) 515-9099
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 4	DATE:	11/22/2022
		UNANNOUNCED	TIME BEGAN:	03:03 PM
MET WITH:	Gainel Malybaeva, Administrator		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Uncleared adults working with residents
Neglect/lack of supervision resulting in residents needs not being met
Staff restrain resident in bed
Food is not stored and served in a safe and healthful manner

INVESTIGATION FINDINGS:

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On 11/22/2022, Licensing Program Analyst (LPA) Tobola conducted an unannounced visit for the purpose of delivering complaint findings. LPA toured the facility, interviewed staff and residents, made observations and reviewed staff records.

The complaint alleges uncleared adults are working with residents. Based on a review of records, staff roster and observations, LPA Tobola found that all staff present (S1, S2) and those providing care were properly associated to the facility. During the investigation, LPA found that resident (R1) receives private care companion services from individual (I1). However, I1 only provides companion services including cooking, exercise, massages and walking. Based on Title 22 Regulation private care coordinators are exempt from fingerprint clearance.
Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221021094048

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: 11/22/2022

NARRATIVE

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Complaint alleges neglect/lack of supervision resulting in residents needs not being met. Based on a tour of the facility, observations of staff S1 and S2, LPA found that caregiver staff were attending to residents throughout the multiple visits, providing continence care, meals and room health checks. In addition, based on interview; resident (R1) informed LPA that they enjoy the staff and feel that they meet R1's level of care. R1 stated that they did not have any concerns with the facility.

Complaint alleges staff restrain resident in bed. Based on a tour of the facility and LPA observations, LPA did not observe any of the residents inappropriately restrained in bed, nor surrounded by any devices or furniture items that restrict the residents' mobility and accessibility.

Complaint alleges food is not stored and served in a safe and healthful manner. Based on a tour of the facility and LPA observations, LPA reviewed facility food supply and found food items both perishable and non-perishable to be stored appropriately with no observed expired or spoiled food items. In addition, food items including frozen meats were labeled with dates when items were stored by staff.

Based on a tour of the facility, interviews with staff and resident, record review, and observations obtained during the investigation the allegations, uncleared adults working with residents, neglect/lack of supervision resulting in residents needs not being met, staff restrain resident in bed and food is not stored and served in a safe and healthful manner are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited during today's visit. Appeal Rights given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022

LIC9099 (FAS) - (06/04)

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