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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800869
Report Date: 08/30/2022
Date Signed: 08/30/2022 02:15:21 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
02/02/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220202091317
FACILITY NAME:SARAH'S BANCROFT DRIVE ADULT HOMEFACILITY NUMBER:
496800869
ADMINISTRATOR:LAWRENCE-FERREIRA, MEGANFACILITY TYPE:
735
ADDRESS:1842 BANCROFT DRIVETELEPHONE:
(707) 823-9365
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 3DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Sarah Lawrence (Licensee)TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident sustained injuries while in care
Facility failed to seek medical attention in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Licensee, Sarah Lawrence and Administrator, Megan Lawrence-Ferreira to deliver findings regarding the complaint allegations above.
It was alleged that resident sustained injuries while in care. During the course of this investigation, The Department investigator conducted interviews with staff, residents and other witnesses, and reviewed records associated to the involved client (C1). Based on interviews conducted and records obtained the investigation revealed that on 1/31/22 C1 was taken to Kaiser Hospital and was diagnosed with a fracture to the left side of their face, blood in their lungs, multiple rib fractures and an unstageable pressure injury. On 2/11/22, C1 passed away due to Acute Hypoxic Respiratory failure. The secondary cause of death was Pneumothorax, Pneumonia and Covid19. Conditions leading to the cause of death was rib and humeral fractures. Based on records review, Supplemental staffing request dated 6/11/21 was approved by North Bay Regional Center indicating that C1 required one on one supervision to provide awake overnight supervision due to behavior challenges, supplemental staffing was approved for 15 hours per day effective 1/1/22 to 1/31/23, but investigation revealed that facility only provided overnight supervision for two to three nights per week.
Continues on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
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-20220202091317
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: SARAH'S BANCROFT DRIVE ADULT HOME
FACILITY NUMBER: 496800869
VISIT DATE: 08/30/2022
NARRATIVE
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Continued from LIC9099...

Also, facility staff failed to notice unstageable pressure injury and any bruises, C1’s Individual Program Plan (IPP) dated 8/13/2020 indicates that C1 requires assistance with personal care including bathing and showering. C1 was receiving home health care but not for wound care. Facility staff did not report to home health or their Physician about pressure injury. LPA will address supplemental staffing issue on a case management inspection.

Regarding allegation of facility failed to seek medical attention in a timely manner. Investigator reviewed records and conducted confidential interviews. Per Administrator, on 1/26/22 C1 had complaints of hip pain. IB conducted confidential interviews with facility staff and they did not witness C1’s fall and no fall was reported. On 1/31/22 C1 was taken to Kaiser Hospital due to “failure to thrive” and C1 was diagnosed with a fracture to the left side of their face, blood in their lungs and multiple rib fractures. Per Dr’s report, the fracture was about one week old due to there being no acute facial swelling on the left side and the contusion underneath the left lower eye was healing. Based on the information obtained by the Department during this investigation, C1 sustained an unexplained injury, had complaints of pain on 1/26/22, and the facility staff failed to seek timely medical attention. The facility is also showing a history of failing to seek timely medical attention after unwitnessed falls or incidents, such as the two other incidents occurred on 3/22/21 and 9/1/21. Regional office will be conducting a Non-compliance Conference with Licensee time and date to be determined. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given. Failure to seek medical care resulted in violation causing injury to person in care $500 immediate civil penalty issued. The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20220202091317
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: SARAH'S BANCROFT DRIVE ADULT HOME
FACILITY NUMBER: 496800869
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2022
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement has not been met as evidence by:
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Administrator agrees to submit a written statement in how the facility staff will ensure that client’s needs are being met by POC due date 8/31/22. Regional office will be conducting a Non-compliance conference with Licensee time and date to be determined.
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Based on Department investigator findings, facility staff failed to notice unstageable pressure injury and any bruises which resulted in C1 sustaining unexplained injuries while in care that poses an immediate risk to the health and safety of clients in care.
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Type A
08/31/2022
Section Cited
CCR
80075(a)
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80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services.
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Administrator/Licensee agrees to write a facility policy regarding timely medical care after client’s falls or incidents of complaint of pain and will provide train staff as to the regulation date and time of training to CCL by POC due date 8/31/22. ***An immediate civil penalty of $500 issued
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Based on records review, C1 sustained an unexplained injury, had complaints of pain on 1/26/22, and the facility staff failed to seek timely medical attention. The facility is also showing a history of failing to seek timely medical attention after unwitnessed falls or incidents, such as the two other incidents occurred on 3/22/21 and 9/1/21 which poses an immediate risk to the health and safety of clients in care.

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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
02/02/2022 and conducted by Evaluator Marisol Cuadra
COMPLAINT CONTROL NUMBER: 21-AS-20220202091317

FACILITY NAME:SARAH'S BANCROFT DRIVE ADULT HOMEFACILITY NUMBER:
496800869
ADMINISTRATOR:LAWRENCE-FERREIRA, MEGANFACILITY TYPE:
735
ADDRESS:1842 BANCROFT DRIVETELEPHONE:
(707) 823-9365
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 3DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
12:52 PM
MET WITH:Sarah Lawrence (Licensee)TIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Reporting requirements
INVESTIGATION FINDINGS:
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LPA Cuadra arrived unannounced to the facility met with Licensee, Sarah Lawrence and Administrator, Megan Lawrence-Ferreira to deliver findings regarding the complaint allegation above.

Regarding allegation of Reporting requirements. Based on records review, observations and confidential interviews conducted with staff. On 2/1/22 CCL received an incident report dated 1/31/22 notifying CCL about C1’s hospitalization. Based on records review of incident report logs indicated that the two other incidents occurred on 3/22/21 and 9/1/21 were reported to CCL as stated on regulations. A finding that the complaint allegation of reporting requirements is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4