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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803764
Report Date: 09/01/2022
Date Signed: 09/01/2022 05:06:49 PM

Substantiated


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
04/04/2022 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20220404141240
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: 33DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Facility failed to meet the needs of the resident




INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a subsequent complaint inspection, on 9/1/22 at approximately 12pm, and met with the Administrator John Wotring. LPA also met with the Health Services Director, Dan O'Brien.

LPA reviewed resident's file, and obtained copies from records. The LPA also reviewed medical records of the resident that were provided to the LPA The LPA had toured the facility with the Administrator. The LPA conducted interviews with staff, and other interested parties regarding the complaint allegations. The investigation revealed that resident(R1) had started having bowel movement changes which were observed as loose stools/diarrhea; Per interview(s) R1's room had to be cleaned by staff, including the resident's rug in their room from loose stool incident, and every other day after the incident occurred. The staff also cleaned resident's bathroom and disinfected it after the incident, and as needed after incident.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
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 6
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
04/04/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220404141240

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: 33DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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9
Resident hygiene needs not being met
Facility is not being kept clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a subsequent complaint inspection, on 9/1/22 at approximately 12pm, and met with the Administrator John Wotring. LPA also met with the Health Services Director, Dan O'Brien.
LPA reviewed resident's file, and obtained copies from records. The LPA also reviewed medical records of the resident that were provided to the LPA The LPA had toured the facility with the Administrator. The LPA conducted interviews with staff, and other interested parties regarding the complaint allegations. The investigation revealed that there was no documentation that the resident was not cleaned and provided hygiene care as needed and required, there was no information provided by staff interviews of the resident not receiving hygiene care when needed. Resident was not seen by the LPA as the resident no longer resided in the facility upon receipt of this complaint.
Continued on LIC9099C..
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20220404141240
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: 09/01/2022
NARRATIVE
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The LPA toured the facility and found the resident's vacated room clean and free from urine and/or feces, including urine and feces odor .It is unknown how the resident's room and bathroom were cleaned and maintained prior to the LPA's inspection. There was differing information obtained from reporting party(s) and others interviewed regarding the allegations.

Based on LPAs observations, record reviews, interviews with staff, interviews with other party(s), there is insufficient information to prove or disprove the allegation of "resident hygiene needs not being met" and "facility is not being kept clean." Although the allegation(s) 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 the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 21-AS-20220404141240
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: 09/01/2022
NARRATIVE
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Per record reviews, there were no progress notes of resident's observed changes and/or any written documentation of resident observed change in condition. There was no documentation that was written and able to be provided and updated as needed in order to ensure the needs of the resident could be addressed by required parties, such as the Physician of the resident. Per record reviews the resident had a prescription for "stool softener" to be given daily, and was still receiving the medication, though the resident was experiencing loose stools; Per record review, Physician had not been notified and/or no written documentation for staff to ensure monitoring of the resident in regards to loose stools, in order to ensure needs of the resident are being met. Resident per interviews had started having loose stools approximately around 3/16 and/or 3/17, 2022. Resident had continued to have issues with bowel movements and was seen by the Physician on 3/22/22. Resident was treated for dehydration and also noted in medical documentation was "resident bowel function was liquid." Resident was prescribed an over the counter medication, Imodium for loose stools. The Physician had the stool softener stopped while resident was having loose stools. Resident was moved out of the facility 3/30/22.

Per the investigation, there was no follow-up documentation on resident's observed changes, no documentation to staff on monitoring the resident for loose stools and hydration due to loose stools, no documentation notifying the Physician.
Based on LPA interviews, and review of information obtained, the investigation has revealed that the allegation of "facility failed to meet the needs of the resident' has been substantiated.

Due to the substantiation of the allegation, deficiency citations will be issued, 7468.2 Additional Personal Rights of Residents in Privately Operated Facilities and 87466 Observation of the Resident -see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Appeal Rights Given.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
04/04/2022 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20220404141240

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: 33DATE:
09/01/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:John Wotring-AdministratorTIME COMPLETED:
05:10 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Facility failed to report an Outbreak
INVESTIGATION FINDINGS:
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5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Alviso conducted a subsequent complaint inspection, on 9/1/22 at approximately 12pm, and met with the Administrator John Wotring. LPA also met with the Health Services Director, Dan O'Brien.
LPA reviewed resident's file, and obtained copies from records. The LPA also reviewed medical records of the resident that were provided to the LPA The LPA had toured the facility with the Administrator. The LPA conducted interviews with staff, and other interested parties regarding the complaint allegations. The investigation revealed that the facility did not have an outbreak to be reported to Public Health and/or licensing at the time allegation made. Based on the investigation, the allegation, of "facility did not report an outbreak", 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 the Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20220404141240
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/02/2022
Section Cited
CCR
7468.2
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7468.2 Additional Personal Rights of Residents in Privately Operated Facilities. a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Licensee/Administrator to ensure that all resident rigths are not violated; Ensure all staff are trained in resident rights by an outside agency. Submit plan of training for staff providing care services, including Administrator, Health DServices Director.
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This requirement was not met based on: LPA's investigation, record reviews, and interviews; Facility did not ensure observed changes of the resident were documented and resident changes were being shared to all staff caregiving to resident 1, ensuring current needs were met. This is an immediate personal rights risk to resident(s) in care.
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Submit proof of training by 9/16/22. Submit plan of correction by 9/2/22.
Type A
09/02/2022
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met based on LPA's investigation, interviews, and
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Licensee/Administrator to ensure that all resident observed changes are documented and brought to the attention of all those required , including faciity staff and resident's Physician. Ensure records are kept updated as needed and shared with staff on all shifts as needed to ensure resident's health and sfety.
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 reviewof records. acility did not ensure observed changes of the resident were documented and resident changes were being shared to all staff caregiving in order to meet resident's current needs-ensuring observed changes are addressed by the Physician and any other required parties. This is an immediate personal rights and health and safety risk to resident(s) in care.
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Submit proof of inservice regarding "Resident Observed Changes" to all staff providing care services, including Administrator and Health Services Director. Submit Proof of correction due 9/16/22. Submit plan of correction by 9/2/22.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6