496803049-11-5-2021-21-AS-CMAZ-C8VNTK-20211118094451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803049
Report Date: 11/05/2021
Date Signed: 11/05/2021 04:57:06 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
06/08/2021 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20210608134335

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: 236	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Administrator, Ferdinand Buot		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff treated resident inappropriately

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Erik Gonzalez-Campos conducted a complaint inspection to deliver findings; LPA met with Ferdinand Buout and Deborah Smith, on 11/5/2021 at approximately 3:15 PM.

The Department LPA reviewed information provided by the reporting party. The allegation of staff treated resident inappropriately was found to be allegations of staff speaking to the resident rudely and loud, staff pushed resident's walker while resident was using it, and resident almost lost their balance, was determined to have been previously investigated, complaint report dated 6/22/2020. LPA reviewed resident files, including resident incidents, medical documentation, and care plans of Resident 1 (R1) and and Resident 2 (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 due to the resident's decline.
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: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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 3

Control Number 21-AS-20210608134335

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: 11/05/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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 the resident and by 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.

The allegation of the resident was treated inappropriately, was found to include an allegation of the resident was not properly reassessed, was determined to have been previously investigated-see complaint report dated 4/20/2021. The Department LPA reviewed information provided by the reporting party(s). The LPA reviewed resident records (R1), including care plans, re-assessment(s), incidents, medical records/ documentation. The LPA reviewed records, and conducted interviews with staff, and other related party(s). The investigation revealed there was a reassessment done on 9/28/2020 by S3; S3 also observed care staff providing services to R1 in residents home, and the responsible party of R1 was present at the time. Per S1 the responsible party had input regarding R1's care needs, and per S1 these were incorporated into the resident's care plan, in the instructions portion. S1 stated a new reassessment started 9/28/20 and was completed 10/2/20 by S3, an RN staff of Varenna. S3 stated R1 has had additional decline due to the diagnosis of Parkinson's, and a reassessment was needed to provide current care needs to R1; Per record review and interviews, S3 reviewed medical documentation, current care plan, resident incidents, observation of care being provided to R1. S3 stated they took into consideration input from R1's responsible party on 9/28/20 during the assessment of R1. S3 used the worksheet tool, points system on care needs of the resident, and from this an updated care plan is created. Per interview with S1, and records review, the reassessment documents were provided to the responsible party (RP) on 10/2/2020, delivered by staff to the RP in a sealed envelope. Per review of a letter dated 10/2/2020, summary of the letter stated to the RP that to please notify administration staff of any family member and/or health care professional(s) that RP would like included in a care conference being set-up to discuss the new care plan and reassessment documentation with RP. Per S1, they had discussed with RP on 10/5/20 that the care conference would be a time to review and discuss the reassessment and care plan, and that RP could have someone/others there, a family member, Physician of the resident, other health care professional but at that time the RP told S1 that they would provide information at a later date. S1 stated to the LPA that no information was provided by RP to S1 or any other staff person of RP's family member or health care professional RP would like to be included and/or notified of the care conference. Per record reviews, LPA observed a reassessment document, worksheet tool, and the service plan from the reassessment started on 9/28/20, and completed 10/2/20 by S3, an RN.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20210608134335

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: 11/05/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA also interviewed reporting party (RP); Reporting party gave conflicting information to the information obtained from other parties during the investigation. RP does not agree with the reassessment that was done, the increased care needs and services, and the increased fees that were noted in documents received on 10/2/2020. Investigation identified that resident’s reassessments were reviewed, and when there were increased needs these may result in increased fees for additional services. There was discussion back and forth between party(s) regarding the increase care service fees. Investigation also showed that reassessments were completed using the appropriate procedures and documentation per facility policies, and financial documentation shows care fees were being paid for care services, including increased fees. Per review of financial payment account records when there was an overpay of care fees the fees were credited to the responsible party as required.

Based on the Departments investigation, interviews, file reviews, and conflicting information obtained during interviews with other related parties there is insufficient information to prove or disprove the allegations of staff spoke to the resident rudely and loud, staff pushed resident's walker while resident was using it and resident almost lost their balance, and resident was not properly reassessed. 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 deficiencies and/or citations issued today.
Exit interview conducted with Ferdinand Buot and Deborah Smith

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3