486804073-12-29-2022-21-AS-KMOA-CNGMYU-20230127090206

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804073
Report Date: 12/29/2022
Date Signed: 12/29/2022 04:54:55 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:	12/29/2022
		UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Kristine Bernardino, Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not dispense medication per physicians orders

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 residents, reviewed staff training files and made observations.

Complaint alleges staff did not dispense medication per physicians orders with resident medications pre-poured over 24 hours prior to administering as well as residents being administered over the counter un-prescribed medications. Based on LPA observations, no additional un-prescribed over the counter medications were observed in resident bedrooms or facility medication cabinet. LPA also did not observed any pre-poured medications for administering the following day.
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: 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 4

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: 12/29/2022

NARRATIVE

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Based on interviews and observations with staff S1, LPA found that staff S1 was able to demonstrate proper medication administration procedures based on Title 22 regulations and the facility medication administration policy. In addition LPA observed the Centrally Stored Medication records to be in order. However, due to conflicting statements from allegation and LPA unable to include staff S2 & S3 in medication administration demonstrated procedures, the allegation is found to be unsubstantiated.

Allegation, staff did not dispense medication per physicians orders are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. 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: 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 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
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:	12/29/2022
		UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Kristine Bernardino, Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not have the required medication training

INVESTIGATION FINDINGS:

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

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 residents, reviewed staff training files and made observations.

Complaint alleges staff do not have the required medication training. Based on a review of training records for staff (S1, S2, S3, S4 & S5), LPA Tobola found that all staff (S1, S2, S3, S4, S5) have received their initial on boarding training and have been documented. LPA received copies of the signed on-board training including medication administration procedures.

Continued onto LIC9099-C

Unfounded

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: 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: 3 of 4

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: 12/29/2022

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	Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation, staff do not have the required medication training are UNFOUNDED. We have found that the complaint allegations were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. No deficiencies cited.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (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: 4 of 4