496803588-4-20-2021-21-AS-BMOS-C2GNT9-20210427104419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803588
Report Date: 04/20/2021
Date Signed: 04/20/2021 02:30:04 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
01/19/2021 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20210119085728

FACILITY NAME:	COUNTRY ROSE ASSISTED LIVING		FACILITY NUMBER:	496803588
ADMINISTRATOR:	ARCHER, LEAH		FACILITY TYPE:	740
ADDRESS:	2273 WEST HEARN AVENUE		TELEPHONE:	(707) 495-0801
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY:	6	CENSUS: 4	DATE:	04/20/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Leah Archer		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care due to staff neglect.
Staff over medicated resident while in care.
Staff did not provide adequate incontinent care to resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert met with **** for the purpose of delivering findings on this complaint. The visit was conducted via tele-visit due to the Covid-19 precautions. LPA did not physically present at the site. Interviews have been conducted with witnesses and parties; documents, including extensive Hospice medical notes, have been obtained and reviewed. The following determinations have been made: Prior to death, Resident ( R1) was a Hospice patient for 7 months due to declining condition; R1 spent 12 days as a resident of the facility before being hospitalized and did not return to facility; R1 left facility on 01/12/2021 and died on 02/23/2021; R1 had documented pressure injuries prior to placement which did reoccur in placement; Hospice staff report, and notes confirm, R1 was at end of life stage and was exhibiting typical symptoms expected when a patient transitions; Hospice staff report that R1 always appeared clean and was offered appropriate nutritious food; Facility staff; facility care notes; Hospice staff indicate R1 often refused food; Death certificate for R1 states cause of death to be sepsis from UTI with contributing factors of exhaustion, dementia, and covid 19; Notes during the time R1 was at facility indicate that R1 was not symptomatic for UTI and Hospice staff indicate non symptomatic UTI's are not routinely treated for Hospice patients; ***Continued page two..

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
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 4

Control Number 21-AS-20210119085728

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: COUNTRY ROSE ASSISTED LIVING	FACILITY NUMBER: 496803588
	VISIT DATE: 04/20/2021

NARRATIVE

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R1 was in considerable pain and was prescribed pain medication; Hospice staff indicate R1's family was resistant to pain medication administration and it is not likely R1 was over medicated; records do not indicate inappropriate administration of pain medication. While R1 may have continued to decline while at the facility, this agency found no indication that staff neglected R1's incontinence care; medication administration; or pressure injury precautions and it appears R1's decline was not unusual for Hospice patient at end of life stage. Although the allegations may have happened or are valid, based upon the records obtained and reviewed, and the statements taken from witnesses and parties, there is not a preponderance of evidence to prove the allegations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
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 4

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
01/19/2021 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20210119085728

FACILITY NAME:	COUNTRY ROSE ASSISTED LIVING		FACILITY NUMBER:	496803588
ADMINISTRATOR:	ARCHER, LEAH		FACILITY TYPE:	740
ADDRESS:	2273 WEST HEARN AVENUE		TELEPHONE:	(707) 495-0801
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY:	6	CENSUS: 4	DATE:	04/20/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Leah Archer		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility did not provide prompt access to Responsible Person to review records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert met with **** this date for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele-visit due to the Covid-19 precautions. LPA did not physically present at the site. Responsible Person for R1 has requested records from R1’s file at the facility. The request was received by the facility via FED-EX on 3/25/2021. On 04/20/2021, this Department made inquiry to the attorney representing R1 and was told that the requested records had not been received from the facility. Based upon the statements made and records reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
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: 3 of 4

Control Number 21-AS-20210119085728

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: COUNTRY ROSE ASSISTED LIVING	FACILITY NUMBER: 496803588
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/04/2021 Section Cited HSC 1569.269(a)(21)	1 2 3 4 5 6 7	1569.269(a)(21)H&S.Residents of residential care facilities for the elderly shall have all of the following rights:… To have prompt access to.. records. Photocopied records shall be promptly provided, not to exceed two business days.....*** Based upon statements made and records reviewed,	1 2 3 4 5 6 7	Facility shall promptly provide copies of records to R1 in compliance with 1569.269(a)(21) as requested and will submit proof of compliance to CCL by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	this requirement has not been met as evidenced by: Facility received written request for records on March 25,2021 and, as of April 20, 2021, the facility has not provided the records. This poses a potential violation of R1’s personal rights.	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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
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: 4 of 4