496801754-7-6-2021-21-AS-BMOS-C4PSWE-20210707141413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801754
Report Date: 07/06/2021
Date Signed: 07/06/2021 10:33:36 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2021 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20210604123123

FACILITY NAME:	WHITE ROSE MANOR		FACILITY NUMBER:	496801754
ADMINISTRATOR:	REMOLLO-SANTOS, GEORGIANA		FACILITY TYPE:	740
ADDRESS:	313 SHEILA COURT		TELEPHONE:	(707) 776-0858
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 6	DATE:	07/06/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Glenda Castle - Staff		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident is being emotionally abused while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of completing the investigation of this complaint. LPA met with *********and delivered this department's findings. Complainant has alleged that facility staff are verbally and emotionally abusive to R1 by yelling at R1 and by causing pain when providing hygiene care. During the course of the investigation, this department has taken statements from staff and residents, reviewed and obtained documents, made observations and conducted unannounced site visits. The following determinations have been made: R1 makes similar accusations to those of Complainant; Facility staff and Administrator deny the allegations; Other residents and family member state the staff are kind and have not observed any abuse of residents by staff; R1 has medical condition rendering R1 in pain and sensitive to being turned by staff; No additional witnesses were located. Although the allegation may be true, based upon statements made and observations, there is not a preponderance of evidence to prove the allegation is, or is not, true. Therefore, the complaint is UNSUBSTANTIATED.

****No citations issued today*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2021

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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