496801812-9-15-2022-21-AS-KMOA-CJQVJF-20220929162839

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801812
Report Date: 09/15/2022
Date Signed: 09/15/2022 01:49:11 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
09/13/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220913120903

FACILITY NAME:	GREEN ACRES MANOR		FACILITY NUMBER:	496801812
ADMINISTRATOR:	HANSEN, JOSEPH		FACILITY TYPE:	740
ADDRESS:	9020 SONOMA HWY 12		TELEPHONE:	(707) 833-1171
CITY:	KENWOOD	STATE: CA	ZIP CODE:	95452
CAPACITY:	15	CENSUS: 13	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator, Elizabeth Lopez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility does not have a sufficient amount of food for residents in care
Staff are not properly storing medications
Staff are not ensuring that residents wear their own clothing
Staff are falsifying medical documentation
Facility is in disrepair
Staff are not ensuring that the facility dishwasher is sanitary

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 09/15/2022 to conduct an initial complaint inspection regarding the above allegations. LPA met with administrator, Elizabeth Lopez.

There is an allegation that the facility does not have a sufficient amount of food for residents in care. During the inspection LPA made observations and interviewed staff. Upon arrival LPA observed staff preparing a beef stew for resident lunch. LPA received a menu for the week. LPA observed an ample amount of perishable and non-perishable food in the pantry, the fridge and two freezers. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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-20220913120903

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: GREEN ACRES MANOR	FACILITY NUMBER: 496801812
	VISIT DATE: 09/15/2022

NARRATIVE

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There is an allegation that staff are not properly storing medications. Medications are stored in locked cabinets in the hallway. LPA verified that medications are kept in their original containers. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that staff are not ensuring that residents are wearing their own clothing. LPA inspected resident bedrooms and observed resident clothes hanging in closets and folded in drawers. Per administrator, resident laundry is done by room which helps keep track of resident possessions. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that staff are falsifying medical documentation. During the inspection LPA reviewed medication administration record (MAR) and conducted interviews. LPA obtained copies of MAR and medication list for 4 out of 13 residents. Interviews and record review revealed that medications are being dispensed per physician’s orders. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that facility is in disrepair. During the inspection LPA toured building and grounds which were clean and in good repair. LPA observed landscapers working on the front yard during the inspection. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that facility staff are not ensuring that the facility dishwasher is sanitary. During the inspection LPA observed the dishwasher operating normally. Dishwasher was clean and sanitary. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with administrator, Elizabeth Lopez and a copy of this report printed for the facility.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
09/13/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220913120903

FACILITY NAME:	GREEN ACRES MANOR		FACILITY NUMBER:	496801812
ADMINISTRATOR:	HANSEN, JOSEPH		FACILITY TYPE:	740
ADDRESS:	9020 SONOMA HWY 12		TELEPHONE:	(707) 833-1171
CITY:	KENWOOD	STATE: CA	ZIP CODE:	95452
CAPACITY:	15	CENSUS: 13	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator, Elizabeth Lopez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are not reporting incidents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced to conduct a complaint investigation regarding the allegation that staff is not reporting incidents. LPA met with administrator, Elizabeth Lopez.

Reporting Party (RP) stated that there was an incident concering Resident 1 (R1) that was not reported to licensing. Community Care Licensing recieved incident report, death report and death certificate for R1 in October of 2019. Therefore we have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit inteview conducted with administrator Elizabeth Lopez, and a copy of this report printed for the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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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