490107656-5-10-2024-21-AS-VBEI-D58TVX-20240513150439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 490107656
Report Date: 05/10/2024
Date Signed: 05/10/2024 09:35:43 AM

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
12/22/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231222163620

FACILITY NAME:	SPRING LAKE VILLAGE		FACILITY NUMBER:	490107656
ADMINISTRATOR:	PRESSEY, JEANIE		FACILITY TYPE:	741
ADDRESS:	5555 MONTGOMERY DRIVE		TELEPHONE:	(707) 538-8400
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	679	CENSUS: 35	DATE:	05/10/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Executive Director, Bill Keck and Health Care Administrator, Dan Skillman.		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Staff refused to administer medication to resident

INVESTIGATION FINDINGS:

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At approximately 8:20AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Executive Director, Bill Keck and Health Care Administrator, Dan Skillman.

During the course of the investigation, the Department requested and reviewed documents, and made observations. There is an allegation that “Staff refused to administer medication to resident.”
Complainant alleges that facility did not provide medication to Resident 1 (R1) on 12/17/2023, 12/18/2023, 12/19/2023, 12/20/2023, 12/21/2023, and 12/22/2023. Complainant alleged that Morphine was not provided to R1 on the following dates, 12/20/2023, 12/21/2023, and 12/22/2023 when R1’s private caregivers requested it, and that facility did not provide Lorazepam (Ativan) to R1. Complainant stated that R1’s private caregivers had documentation on when medication was requested and when medication was refused to be given. Attempts to obtain private caregiver contact information and the documentation were unsuccessful.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

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-20231222163620

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: SPRING LAKE VILLAGE	FACILITY NUMBER: 490107656
	VISIT DATE: 05/10/2024

NARRATIVE

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Continued from LIC9099

Review of R1’s Electronic Medication Administration Record (EMAR) for December 2023, showed that R1 had two routine morphine orders to be given twice a day. Review of R1’s EMAR indicated that the facility administered the routine morphine orders on 12/15/223, 12/16/23, 12/17/23, and 12/18/23. These two orders were discontinued on 12/15/2023 and 12/18/2023. R1 also had a PRN morphine order to be administered as needed for pain or trouble breathing and a PRN Lorazepam order to be administered as needed for anxiety. Review of R1’s EMAR showed that facility staff administered PRN Morphine and PRN Lorazepam two times to R1 on 12/22/2023. Facility Progress Notes stated that on 12/19/2023, R1’s private caregiver said R1 needed Ativan. Per notes, the facility nurse observed R1 to be calm and peaceful. When the facility nurse asked R1 if they wanted Ativan, R1 stated no. Facility Progress Notes also stated that on 12/21/2023, the facility nurse received a call from R1’s private caregiver asking for Ativan. Facility Nurse and Certified Nursing Assistant (CNA) went to R1 to assess. Facility nurse and CNA observed R1 to be in a calm and pleasant mood. When R1 was asked how they were feeling, they stated they were fine. When R1 was asked if they felt anxious or if they wanted Ativan, R1 stated no. Review of R1’s Physician’s Report, dated 12/25/2022, stated that R1 can communicate their needs.

Based on document review and observations made, this allegation is Unsubstantiated. A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to Executive Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2024

LIC9099 (FAS) - (06/04)

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