496803049-6-22-2020-21-AS-CMAZ-BQY7AP-20200626212949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803049
Report Date: 06/22/2020
Date Signed: 06/22/2020 05:39:01 PM

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
02/19/2020 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200219180556

FACILITY NAME:	VARENNA AT FOUNTAINGROVE		FACILITY NUMBER:	496803049
ADMINISTRATOR:	BUOT, FERDINAND		FACILITY TYPE:	741
ADDRESS:	1401 FOUNTAINGROVE PKWY		TELEPHONE:	(707) 526-1226
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	322	CENSUS:	DATE:	06/22/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ferdinand Buot-Administrator/ED		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff spoke to resident rudely and loud
Staff pushed resident's walker while resident was using it, and resident almost lost their balance

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a televisit inspection, on 6/22/2020 at approximately 1:00PM to deliver findings. LPA conducted the televisit with Administrator Ferdinand Buot. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit.

LPA reviewed resident files, including resident incidents, medical documentation, and care plans of R1 and R2. LPA conducted file reviews, interviews with staff, and various outside parties. The investigation revealed that there was an incident reported by R1 regarding when care staff had been to the apartment providing evening care services to R2. Due to R2's diagnosis the resident needs two(2) to three (3)caregivers depending on R2's strength at the time, and also due to the resident's decline.

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2020

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-20200219180556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VARENNA AT FOUNTAINGROVE	FACILITY NUMBER: 496803049
	VISIT DATE: 06/22/2020

NARRATIVE

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A total of three (3) staff were in the apartment of the residents (R1 & R2) providing needed evening care to R2. During staff providing care to R2 an incident between staff 3 and R1 was reported by both resident and staff 3. R1 reported that staff person was violating their personal rights and being abusive. Staff denied any pushing of the resident or the walker, yelling, speaking loud or rude to R1 or any residents at any time.

Based on LPAs investigation, interviews, file reviews, and conflicting information gathered during interviews with other related parties there is insufficient information to prove or disprove the allegations of Staff spoke to resident rudely and loud, Staff pushed resident's walker while resident was using it, and resident almost lost their balance. Although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.
No citations issued during today's visit.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2020

LIC9099 (FAS) - (06/04)

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