496803049-4-20-2021-21-AS-HDBI-C2HMNF-20210428094526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803049
Report Date: 04/20/2021
Date Signed: 04/20/2021 03:05:10 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
10/19/2020 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201019134201

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:	04/20/2021
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Ferdinand Buot-Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident's personal information was not kept confidential

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

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 5

Control Number 21-AS-20201019134201

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: 04/20/2021

NARRATIVE

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Per LPA's interview with administration staff (S1), an activity assistant/staff person (S2), on 10/2/20 at approximately 5PM, delivered a letter that was folded, not in a sealed envelope, to R1's responsible party. Per S1, on 10/2/2020 a second letter that was sealed in an envelope was delivered by staff 2 at approximately 6:45PM to R1's responsible party. The letters contained resident information that is considered confidential.

LPA was provided a copy of a written statement by S2 regarding the delivery by S2 of two letters to R1's responsible party; Summary of the letter was stating that S2 had delivered two letters to the responsible party on 10/2/20 at separate times, one letter folded and the other letter in a sealed envelope. S2 had stated in the letter that the letters were not opened during the delivery by S2.

Per the investigation, the letter that was delivered folded and not in a sealed envelope left the contents of the letter accessible to others, the folded letter provided no safeguard of residents personal/confidential information from possibly being seen/read by others.

Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of resident's personal information was not kept confidential, has been substantiated.

Due to the substantiation of the allegation, a citation, 87468.1(a)(1), will be cited today-see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Appeal Rights Given.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 21-AS-20201019134201

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/30/2021 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1(a)(1) Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons. Based on LPA's investigation, review of records and interviews, Staff 1 stated that staff 2 was sent to deliver two letters at separate times on 10/2/20, to R1's responsible party;	1 2 3 4 5 6 7	Administrator to ensure that staff, including the facility's administration staff have an in-service training regarding "Personal Rights" of residents in care.
	8 9 10 11 12 13 14	The letters contained resident(s) confidential information. The first letter delivered was folded in half and not in a sealed envelope, and the second letter delivered later that same day was in a sealed envelope. The letter delivered folded in half was not ensuring residents right to confidentiality, as it left the contents in the letter accessible to be read/seen by others. This is a potential risk of personal rights of a resident(s) in care.	8 9 10 11 12 13 14	Submit a copy of topics covered, including information of trainer/qualifications, attendees, date(s), and time spent. POC due by 4/30/21.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
10/19/2020 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201019134201

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:	04/20/2021
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Ferdinand Buot-Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident was not properly reassessed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a televisit inspection, on 4/20/21 at approximately 2:15PM. LPA spoke with Administrator Ferdinand Buot. The inspection is being conducted by tele-inspection due to COVID-19 precautions. The reader is advised that the LPA did not physically make a site visit.

The 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;
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

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 5

Control Number 21-AS-20201019134201

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: 04/20/2021

NARRATIVE

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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. LPA also interviewed reporting party; 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.

Based on LPA's observations, record reviews, interviews with staff, and conflicting information obtained from other related parties, there is insufficient information to prove or disprove the allegation of Resident was not properly reassessed. 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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021

LIC9099 (FAS) - (06/04)

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