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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803737
Report Date: 04/15/2022
Date Signed: 04/15/2022 02:40:00 PM

Unfounded


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
03/15/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20220315103227
FACILITY NAME:SUNRISE VILLA SANTA ROSAFACILITY NUMBER:
496803737
ADMINISTRATOR:OLSON, KATHLEENFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRTELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
02:50 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Resident sustained an unexplained injury while in care
Resident is not receiving adequate wound care causing residents pressure injuries to worsen
Staff are crushing resident medications to hide/camoflauge higher dosage provided to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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9
10
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12
13
The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 04/15/2022 to deliver findings for the above allegations. LPA met with Health Services Director (HSD) Teresa Weerts.

There is an allegation that a resident sustained an unexplained injury while in care. Reporting Party (RP) stated to LPA on 03/18/2022 that they observed Resident 1 (R1) with a bruise on the right side of their face. LPA observed bruise on 03/16/2022 during tour of facility The Santa Rosa Regional Office received an incident report on 03/14/2022 documenting the injury. LPA performed record review of R1’s resident file on 03/16/2022. LPA determined from record review that injury was documented and appropriate measures were taken. The agency has investigated the allegation that resident received an unexplained injury while in care. We have found that the allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Continued on LIC 9099C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
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
Control Number 21-AS-20220315103227
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: SUNRISE VILLA SANTA ROSA
FACILITY NUMBER: 496803737
VISIT DATE: 04/15/2022
NARRATIVE
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There is an allegation that resident is not receiving adequate wound care causing the resident’s pressure injuries to worsen. RP stated to LPA on 03/16/2022 that Resident 2 (R2) developed pressure injuries at a nursing home they were a resident of previously. Record review on 03/16/2022 revealed that R2 moved in on 03/02/2022. LPA conducted interview with ED, HSD, and MCD on 03/16/2022. Directors stated that R2 is receiving hospice care and that hospice come to the facility to provide wound care. LPA contacted hospice services provider on 03/21/2022. Hospice nurses stated to LPA that on 03/08/2022 R2 refused a skin assessment but that facility was able to provide photographs of pressure injuries to hospice nurse. Hospice indicated to LPA that pressure injuries are healing, and that facility assists with wounds as needed. LPA requested hospice records which were received on 03/30/2022. Hospice records indicate pressure injuries are healing. The agency has investigated the allegation that resident is not receiving adequate wound care causing the resident’s pressure injuries to worsen. We have found that the allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

There is an allegation that staff are crushing resident medications to hide/camouflage higher dosage provided to resident. RP stated on 03/18/2022 that medication is being crushed and put in apple sauce to be given to R2. Hospice records received on 03/30/2022 note on 03/11/2022 that physician has given order that medication may be crushed to assist with swallowing. LPA interview with staff on 03/29/2022 revealed that some medications are crushed for R2 to assist in swallowing. Staff indicated they have a physician's order to crush medicine if needed. The agency has investigated the allegation that that staff are crushing resident medications to hide/camouflage higher dosage provided to resident. We have found that the allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted with Teresa Weerts and a copy of this report printed for the facility.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 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
03/15/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20220315103227

FACILITY NAME:SUNRISE VILLA SANTA ROSAFACILITY NUMBER:
496803737
ADMINISTRATOR:OLSON, KATHLEENFACILITY TYPE:
740
ADDRESS:4225 WAYVERN DRTELEPHONE:
(707) 538-2590
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:114CENSUS: DATE:
04/15/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:TIME COMPLETED:
02:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handled resident in a rough manner
Resident is being chemically restrained by staff
Resident diapering needs are not being met
Resident is not provided daily activities
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 04/15/2022 to deliver findings for the above allegations. LPA met with Health Services Director (HSD) Teresa Weerts.

There is an allegation that staff handled resident in a rough manner. RP stated on 03/18/2022 that residents do not wish to be in facility and staff will be forceful with residents. LPA toured memory care unit on 03/16/2022 and 04/15/2022. Staff were observed interacting with residents during activity time and meal time. 4 out of 4 staff indicated during interviews that they have never observed staff be rough with residents. 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.

Continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20220315103227
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: SUNRISE VILLA SANTA ROSA
FACILITY NUMBER: 496803737
VISIT DATE: 04/15/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
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32
There is an allegation that resident is being chemically restrained by staff. RP stated to LPA on 03/18/2022 that R2 is being sedated with Lorazepam. LPA obtained medication administration record (MAR) for R2 on 03/16/2022 and additional hospice documentation from facility on 03/18/2022. Hospice documents indicate that R2 is to be given Lorazepam twice a day. MAR shows that R2 was given Lorazepam consistent with the physician’s orders. 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.

There is an allegation that resident diapering needs are not being met. RP stated on 03/18/2022 that R2 is not being changed appropriately and that it is causing her pressure injuries to worsen. RP has not seen pressure injuries. Staff interview with LPA on 03/29/2022 revealed that R2 is changed 3 times a day or as needed. During tour of facility on 03/16/2022 and 04/15/2022 LPA did not observe soiled residents. 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.

There is an allegation that resident is not being provided with daily activities. RP stated on 03/18/2022 that residents sit in their chairs all day and that no activities are provided. LPA toured facility on 03/16/2022 and observed residents in memory care unit sitting in the common area watching a televised music performance. R2 was with group of residents. LPA observed residents in assisted living engaged in a group discussion with staff member. Staff stated to LPA that residents follow an activity schedule in memory care unit. LPA requested activity scheduled on 04/08/2022. Facility provided activity schedule for the entire month of April. 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.

Exit interview conducted with Teresa Weerts. A copy of this report was printed for the facility.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4