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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803764
Report Date: 03/18/2022
Date Signed: 03/18/2022 03:23:01 PM

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
02/15/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220215152441
FACILITY NAME:PRIMROSE ALZHEIMER'S LIVING INCFACILITY NUMBER:
496803764
ADMINISTRATOR:WOTRING, JOHN JFACILITY TYPE:
740
ADDRESS:2080 GUERNEVILLE RDTELEPHONE:
(707) 578-8360
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:50CENSUS: 35DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
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5
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7
8
9
Lack of supervision resulting in resident injury and possible death


INVESTIGATION FINDINGS:
1
2
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4
5
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7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Dina Alviso conducted a complaint inspection, on 3/18/22, and met with Administrator John Wotring. LPA interviewed five (5) staff, and reviewed resident files. The LPA interviewed other parties in relation to the complaint investigation. The investigation revealed that R1 was a fall risk, and was on a fall risk care plan. R1 was a resident who loved to walk, move around the facility, and was a resident who loved talking a lot. R1 used a walker to ambulate but would at times forget to use it, and staff stated they would bring the walker to R1 when needed, and remind R1 that they needed to use it for walking. R1 also used a wheelchair on days they felt more tired than usual. Per staff, R1 was said to use the walker most days, and at times when R1 didn't have the walker, staff reminded R1 to use it, and R1 would get mad at staff when they did this. Staff stated that one time R1 was upset and didn't want staff assistance, R1 was put in a wheelchair, and R1 pushed theirself out the door by using their feet mostly; Staff watched R1 from the doorway, after a short while the staff was able to assist R1 and redirect R1 back inside.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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-20220215152441
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: PRIMROSE ALZHEIMER'S LIVING INC
FACILITY NUMBER: 496803764
VISIT DATE: 03/18/2022
NARRATIVE
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Per review of R1's care plan, and per interviews with staff, R1 was a fall risk, and was on a fall risk care plan but R1 was not on a one to one care staff need. R1 was assessed by facility staff to be a fall risk due to medical documentation and personal history obtained from the Power of Attorney (POA). R1 was supervised, and care needs met, per staff interviews, and LPA's interview with other party(s) related to the investigation. Per LPA's file review, upon R1's admittance into the facility, there is documentation identifying R1 as a fall risk, and information provided regarding falls/falling stating that there is no way to ensure a fall never happens but to ensure a general level of supervision to residents, and that staff will strive to keep a resident from falling, and that even with total supervision of a resident, this may not prevent a resident from falling, This document is signed by the POA of the resident. Per interview with (S1 and S2) R1 had a fall on 2/12/22 as R1 had left the dining room , and walked into the center hallway. Staff (2)RN who was doing paperwork in the dining area heard R1 fall, and rushed out to assess R1, other staff assisted as needed. Staff assessed R1 as having hit their head which resulted in an injury, and contacted 911 immediately; 911 was contacted due to the resident's sustained head injury, and medication the resident was on. Per interview with staff, the 911 emergency medical services (EMS) arrived quickly, and medical attention for R1 was obtained about 10 minutes after the incident occurred.

There was differing information obtained from reporting party regarding the allegation. There was no obtained information by the LPA to support the allegation, Lack of supervision resulting in resident injury and possible death.

Based on LPAs observations, record reviews, interviews with staff, interviews with other party(s), and conflicting information obtained from other related party(s), there is insufficient information to prove or disprove the allegation of Lack of supervision resulting in resident injury and possible death. 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 citations/deficiencies.
Exit interview conducted with John Wotring, Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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, 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
02/15/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220215152441

FACILITY NAME:PRIMROSE ALZHEIMER'S LIVING INCFACILITY NUMBER:
496803764
ADMINISTRATOR:WOTRING, JOHN JFACILITY TYPE:
740
ADDRESS:2080 GUERNEVILLE RDTELEPHONE:
(707) 578-8360
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:50CENSUS: 35DATE:
03/18/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to seek timely medical attention
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Dina Alviso conducted a complaint inspection, on 3/18/22, and met with Administrator John Wotring. LPA interviewed five (5) staff, and reviewed resident files. The LPA interviewed other parties in relation to the complaint investigation. The investigation revealed that R1 was a fall risk, and was on a fall risk care plan. R1 was a resident who loved to walk, move around the facility, and was a resident who loved talking a lot. R1 used a walker to ambulate but would at times forget to use it, and staff stated they would bring the walker to R1 when needed, and remind R1 that they needed to use it for walking. R1 also used a wheelchair on days they felt more tired than usual.

Per interview with (S1 and S2) R1 had a fall on 2/12/22 as R1 had left the dining room, and walked into the center hallway. Staff (2)RN who was doing paperwork in the dining area heard R1 fall, and rushed out to assess R1, other staff assisted as needed. Staff assessed R1 as having hit their head which resulted in an injury, and contacted 911 immediately; 911 was contacted due to the resident's sustained head injury, and medication the resident was on.
Continued on LIC9099C..
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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-20220215152441
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: PRIMROSE ALZHEIMER'S LIVING INC
FACILITY NUMBER: 496803764
VISIT DATE: 03/18/2022
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
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31
32
 Per interview with staff, the 911 emergency medical services (EMS) arrived quickly, and medical attention for R1 was obtained about 10 minutes after the incident occurred. Per interviews, and file reviews, the resident went out 911, on 2/12/22, after having a fall that resulted in a head injury. There was differing information obtained from reporting party regarding the allegation. There was no obtained information by the LPA to support the allegation per the investigation by the LPA.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation, Facility failed to seek timely medical attention, is Unfounded. We have found that the complaint allegation was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
No citations/deficiencies.
Exit interview conducted with John Wotring, Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4