496803470-4-29-2022-21-AS-HDBI-CEGVNG-20220516163507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803470
Report Date: 04/29/2022
Date Signed: 04/29/2022 02:25:21 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
02/28/2022 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20220228153701

FACILITY NAME:	REDWOOD VISTA RESIDENTIAL CARE HOME		FACILITY NUMBER:	496803470
ADMINISTRATOR:	ANGELICA MARTINEZ		FACILITY TYPE:	740
ADDRESS:	8052 WHIPPOORWILL COURT		TELEPHONE:	(707) 620-0243
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Licensee, Angelica Martinez		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are forcing residents to sleep
Staff did not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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

Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegations and met with Licensee, Angelica Martinez.

During investigation, LPA conducted interviews, reviewed documents and made observations.

Staff are forcing residents to sleep, Staff did not treat resident with dignity and respect – Complaint alleges that a caregiver came into a resident’s room stating that the resident needed to go to sleep. Resident verbalized that they wanted to continue reading their book, but caregiver insisted. Interviews revealed that resident was seated in a chair reading around 8:00pm when a caregiver came in and told the resident that it was time to get ready for bed. The resident refused so the caregiver attempted to remove a book from the resident’s lap resulting in the resident getting upset.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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 4

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
02/28/2022 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20220228153701

FACILITY NAME:	REDWOOD VISTA RESIDENTIAL CARE HOME		FACILITY NUMBER:	496803470
ADMINISTRATOR:	ANGELICA MARTINEZ		FACILITY TYPE:	740
ADDRESS:	8052 WHIPPOORWILL COURT		TELEPHONE:	(707) 620-0243
CITY:	WINDSOR	STATE: CA	ZIP CODE:	95492
CAPACITY:	6	CENSUS: 5	DATE:	04/29/2022
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Licensee, Angelica Martinez		TIME COMPLETED:	02:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff engaged into a physical altercation with a resident while in care

INVESTIGATION FINDINGS:

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

Licensing Program Analyst Willis arrived unannounced to deliver findings regarding the above complaint allegation and met with Licensee, Angelica Martinez.

Staff engaged into a physical altercation with a resident while in care – Complaint alleges that during an incident where a resident refused to go to bed, the involved caregiver was pushing the resident physically resulting in the resident’s watch breaking. During visit on March 2, 2022. LPA observed the noted resident’s broken watch, however, LPA was unable to confirm through interviews whether there was a physical altercation between the caregiver and the resident.

A finding that the complaint allegation staff engaged into a physical altercation with a resident while in care was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20220228153701

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: REDWOOD VISTA RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803470
	VISIT DATE: 04/29/2022

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

Continued from LIC9099

The allegations that staff are forcing residents to sleep and staff did not treat resident with dignity and respect is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20220228153701

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: REDWOOD VISTA RESIDENTIAL CARE HOME	FACILITY NUMBER: 496803470
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/04/2022 Section Cited HSC 1569.269	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:…(8) To make choices concerning their daily life in the facility. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above by caregiver attempting to make a	1 2 3 4 5 6 7	Licensee agrees to contact the Long Term Care Ombudsman and set an appointment for an in-service training for all staff regarding Personal Rights. Licensee to submit planned date ot training to CCL no later than, 5/4/2022,
	8 9 10 11 12 13 14	resident go to bed by removing their book despite resident verbalizing that they did not want to go to bed, which poses a potential personal rights risk to persons in care.	8 9 10 11 12 13 14
	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: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4