496803588-4-10-2025-21-AS-BMOS-DFSPYH-20250416114359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803588
Report Date: 04/10/2025
Date Signed: 04/10/2025 09:47:41 AM

Unsubstantiated

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
03/05/2025 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250305104745

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: 5	DATE:	04/10/2025
		UNANNOUNCED	TIME BEGAN:	08:44 AM
MET WITH:	Rosa Ascencio (staff)		TIME COMPLETED:	10:02 AM

ALLEGATION(S):

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-Facility staff hit residents in care.
-Facility staff speak inappropriately to residents in care.
-Facility staff are not serving nutritious meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Rosa Ascencio (staff).

Facility staff hit residents in care. Per Reporting Party, on 1/25/25 staff (S1) was observed "hitting" a resident (R2) and resident (R3) during dinner time after R2 kept asking to see their long-deceased mother. In response to R2’s inquires, S1 admonished R2 “your mother has been dead a long time” when R2 continued to be distressed wanting to visit their mother, S1 responded by hitting/slapping R2 on their arm. Then R2 responded “you shouldn’t hit them like that” resulting in S1 walked over to R3 and hit them on or around their arm too. Based on records review, the licensee provided LPA with a report filed with Santa Rosa Police Department SR#250001691.0 where it was reported that the owner of the facility was observed slapping two unknown victims during dinner. The report has an unfounded case determination. LPA conducted 10-day visit on 03/11/25 toured the facility, made observations, and conducted interviews with staff and residents in care. Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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 3

Control Number 21-AS-20250305104745

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: COUNTRY ROSE ASSISTED LIVING	FACILITY NUMBER: 496803588
	VISIT DATE: 04/10/2025

NARRATIVE

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Continue from LIC9099...

Based on confidential interviews conducted with (R2, R4, R5 & R6) staff who provide care and supervision are described as supportive individuals, residents disclosed that they feel safe at the house, they are not scared to express their thoughts, and they didn’t have any concerns regarding been hit or slapped by any staff or Licensee. Additionally, LPA conducted interviews with staff (S1, S2, S3 & Licensee) did not reveal any indication that staff could be handling residents in a rough manner by hitting or slapping them on their arms and they will reach out to their Supervisor if ever observed any staff hitting or slapping residents in care. Therefore, LPA was unable to determine if allegation could happen at a prior date by S1 who was providing care and supervision during the time of the alleged incidents. A finding that the complaint allegation occurs of facility staff hit residents in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation of facility staff speak inappropriately to residents in care. The Reporting party states that S1 treats resident (R1) with rudeness and disrespect, when S1 was confronted their response was that R1 “asked too many questions”. LPA conducted 10-day visit on 03/11/25 toured the facility, made observations, and conducted interviews with staff and residents in care. Based on confidential interviews conducted with residents (R2, R4, R5 & R6) and staff (S1, S2, S3 & Licensee), there is no leading information obtained from their verbal statements resulting in inappropriate treatment or any type of rudeness or disrespect expressed from staff at the facility. A finding that the complaint allegation occurs of facility staff speak inappropriately to residents in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Continued on LIC9099C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 21-AS-20250305104745

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: COUNTRY ROSE ASSISTED LIVING	FACILITY NUMBER: 496803588
	VISIT DATE: 04/10/2025

NARRATIVE

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Continued from LIC9099C...

The last allegation regarding facility staff are not serving nutritious meals. According to Reporting Party, the quality of the food served is not fresh, they been served always canned or processed foods. An outside party have conducted a visit on 2/14/25 and observed what appeared to be canned pork, beans and potato salad been served for dinner. LPA conducted facility annual, and 10-day visit on 03/11/25 toured the facility, made observations, and conducted interviews with staff and residents in care. Based on observations made by LPA, there was a menu posted on the wall with food options, but it appears that menu is not followed due to staff cooks according to resident’s preferences expressed during the day. Also, LPA observed three residents having breakfast at the table and one resident on a wheelchair eating their breakfast and watching tv. Breakfast served included oatmeal with strawberries, hot chocolate and water. During lunch time, residents were served with chicken and veggies, juice and fruits including banana and strawberries. Although, during the tour of the facility, LPA observed at least two days of perishable and one week of non-perishable foods, LPA suggested to licensee about the benefits of having an ample variety of food supply and a technical advisory was issued to document the conversation. Based on records review, five out of five resident’s physician reports and care plans do not indicate that any resident have a specialized diet requirement on file. Based on confidential interviews conducted with residents (R2, R4, R5 & R6) did not reveal any concerns, challenges or incidents with the food service provided by the facility. Interviews conducted with staff (S1, S2 & S3) confirms that food services are adequate for residents in care, which includes resident’s food options preferences. A finding that the complaint allegation occurs of facility staff are not serving nutritious meals is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during today's inspection. Exit interview conducted with staff and copy of this report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC9099 (FAS) - (06/04)

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