496803544-4-30-2021-21-AS-BMOS-C2PNSV-20210504104347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803544
Report Date: 04/30/2021
Date Signed: 04/30/2021 11:19:58 AM

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
12/28/2020 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201228111141

FACILITY NAME:	LITTLE BIRD ASSISTED LIVING		FACILITY NUMBER:	496803544
ADMINISTRATOR:	FRANCO, KATIE		FACILITY TYPE:	740
ADDRESS:	511 WEBSTER STREET		TELEPHONE:	(707) 559-5793
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94952
CAPACITY:	6	CENSUS: 6	DATE:	04/30/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Kate Franco - Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff are not meeting resident's needs.

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes conducted a telephone visit due to COVID-19 unannounced for the purpose of closing the investigation and met with Kate Franco – Administrator.

On 12/21/2020, LPA Fernandes-Goes acquired documentation; conducted interviews on 1/21/2021, & 4/28; and on 1/21/2021 LPA and SCPH (Sonoma County Public Health) virtually toured the facility and made observations. During documentation review on file, resident’s POAs and staff interviews, LPA learned that facility seems to have enough staff to meet the needs of residents and is aware of their needs. In addition, facility has restarted activities which are being conducted at times individualized such as nail polish, and Friday movie nights, and yoga once a week is a group activity.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

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-20201228111141

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: LITTLE BIRD ASSISTED LIVING	FACILITY NUMBER: 496803544
	VISIT DATE: 04/30/2021

NARRATIVE

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Facility has awake staff at night shift as per facility program and policy. LPA observed virtually during visit that occurred on 1/21/2021 resident’s bedrooms, and required postings for COVID. Documentation provided by the facility shows a shower schedule which as per facility manager Chris has been performed except when resident refuses a shower. If resident refuses a shower, shower is rescheduled for next day. In addition, residents are to be changed as needed during all shifts including overnight shift – NOC shift. Based on documentation reviewed (on file), interviews (see LIC 812s), and observations LPA wasn’t able to prove or disprove the allegation stated above.

A finding that the complaint allegation of “Staff are not meeting resident’s needs.” 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.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

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