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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803289
Report Date: 03/29/2022
Date Signed: 03/29/2022 02:46:40 PM

Substantiated


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
02/04/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220204144217
FACILITY NAME:BEACHWOOD HOUSE, INC.FACILITY NUMBER:
496803289
ADMINISTRATOR:CABIE, BENJAMINFACILITY TYPE:
735
ADDRESS:1177 BEACHWOOD DRIVETELEPHONE:
(707) 332-9865
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:4CENSUS: 4DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Jhannell Edmalin (House Manager)TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility does not allow resident visitation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with House Manager, Jhanell Edmalin to deliver findings regarding the complaint allegation above. Licensee was not present during this visit, but was available by phone and gave authorization to house manager to sign the report. LPA conducted risk assessment with staff at facility entrance.
It was alleged that Facility does not allow resident visitation. Reporting Party stated that staff at the facility will not allowed them to visit client (C1). During the investigation LPA requested and reviewed records, made observations at the facility and conducted interviews. Based on interviews conducted with House manager it was confirmed that clients were not allowed to receive visitors as instructed by Licensee due to public health guidance. Based on a written response dated 3/5/22 from Licensee, Richard Hire the facility was limiting visits to essential visitors, the families were allowed to have virtual visits through zoom but no visits inside the facility. However, State Public Health Order as of August 5, 2021 was amended on August 26, 2021 requiring facilities to develop and implement processes for verifying the vaccination status of all visitors seeking indoor visitation. Continues on LIC9099C…
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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-20220204144217
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: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289
VISIT DATE: 03/29/2022
NARRATIVE
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Continued from LIC9099…

On 8/27/21 Community Care Licensing issued PIN 21-40-ASC to all adult and senior care program residential licensees and provided updated guidance on visitation, testing, vaccination verification guidance for visitors related to Covid19. PIN 21-40-ASC advises the licensee of each facility that they must allow outdoor and indoor visitation, including in-room visitation at all times if the visitor meets the requirements for indoor visitations with screening, maintaining physical distance and regardless of vaccination status or test result, all visitors must wear a well-fitted face mask. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20220204144217
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: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2022
Section Cited
CCR
85072(b)(4)
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85072 Personal Rights (b) The licensee shall insure that each client is accorded the following personal rights: (4) To have visitors… visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients. This requirement has not been met as evidence by:
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Licensee will ensure that residents rights are maintained, and clients will be able to receive visitors. Licensee will submit a self-certification (LIC9098) that all staff had been notified about regulation by POC due date.
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Based on records review of the facility visitor’s sign-in sheet and interviews conducted with house manager, the facility was not allowing visitors to clients in care which poses a potential risk to the health and safety of clients in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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, 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
02/04/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220204144217

FACILITY NAME:BEACHWOOD HOUSE, INC.FACILITY NUMBER:
496803289
ADMINISTRATOR:CABIE, BENJAMINFACILITY TYPE:
735
ADDRESS:1177 BEACHWOOD DRIVETELEPHONE:
(707) 332-9865
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:4CENSUS: 4DATE:
03/29/2022
UNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Jhannell Edmalin (House Manager)TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility did not notify responsible party regarding resident's change in condition.
Facility did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with House manager, Jhanell Edmalin to deliver findings regarding the complaint allegations above.

It was alleged by reporting party that facility did not notify responsible party regarding resident's change in condition. Reporting party alleges that facility staff nor Regional Center does not communicate any changes of condition of C1 to them. Based on records review, client (C1) is a conserved adult since 7/10/1997. On 2/28/22 it was submitted a letter to CCL dated 2/23/22 from the Fiduciary/Responsible Party for C1 who provided proof including letter of Conservatorship since 7/10/1997 and notifying LPA that the facility staff are in contact with their office on a regular basis and are aware of all major incidents involving C1’s medical conditions including but not limited to hospitalizations, significant dental work, vaccinations, changes in medications and physicians, and on-going issues pertaining to disruptive family visits.
Continues on LIC9099C…

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
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-20220204144217
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: BEACHWOOD HOUSE, INC.
FACILITY NUMBER: 496803289
VISIT DATE: 03/29/2022
NARRATIVE
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Continued from LIC9099A…

The fiduciary expressed their confidence if a noteworthy change in C1’s condition occurs, they would be made aware of it immediately. During interviews with house manager provided proof of consistent online communication between C1's responsible party and facility staff about C1’s change of condition.

A finding that the complaint allegations “facility did not notify responsible party regarding resident's change in condition” is unsubstantiated meaning that 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.

During investigation LPA conducted interviews with staff and various outside parties, reviewed incident reports, facility records including C1’s personal plan. Complainant alleges that the facility did not seek medical attention for client in a timely manner. Per Reporting party, C1 had a hospitalization back in 2018 where they almost die from an infection. During records review, the facility provided health care documentation and C1’s Individual Program Plan (IPP) dated 9/23/2018 confirmed that C1 was hospitalized. However, medical records and IPP did not indicate that the facility neglected to seek medical attention in a timely manner resulting in C1’s hospitalization. Based on records review, C1 had been seen by their Physician in a regular basis and has attended to their scheduled dental and medical appointments. A finding that the complaint allegation that facility did not seek medical attention for client in a timely manner is unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred, therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5