496803796-9-16-2020-21-AS-CMAZ-BVXVUG-20201203154443

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803796
Report Date: 09/16/2020
Date Signed: 09/16/2020 06:48:28 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
05/08/2020 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200508171851

FACILITY NAME:	WILLOW GLEN HOME		FACILITY NUMBER:	496803796
ADMINISTRATOR:	MADRID, ORLANDO U.		FACILITY TYPE:	740
ADDRESS:	4750 COUNTRY CLUB DR		TELEPHONE:	(707) 708-2199
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	6	CENSUS:	DATE:	09/16/2020
		UNANNOUNCED	TIME BEGAN:	05:45 PM
MET WITH:	Zoe Teeter-Licensee		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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Residents needs are not being met.
Facility safety measures are not addressing resident's behaviors.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Dina Alviso, conducted a televisit complaint inspection, and met with Licensee Zoe Teeter on 9/16/20 at approximately 5:45PM. LPA conducted this inspection to deliver findings on the investigation. A televisit was conducted due to the Covid 19 Pandemic. Reader is advised the LPA did not make a site visit.

The LPA obtained pertinent documents for the investigation. The LPA reviewed resident (R1) records, including medical records, and resident incidents. LPA also identified through interviews and record reviews who the POA responsible party is, and other family members who have been in touch with the facility regarding R1.

Continued on LIC9099C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200508171851

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: WILLOW GLEN HOME	FACILITY NUMBER: 496803796
	VISIT DATE: 09/16/2020

NARRATIVE

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The investigation revealed that resident (R1) had moved into the facility recently from living independently in an apartment. R1 had previously been very independent until resident started to decline rapidly. Per records, R1 had a rapid decline and needed assistance with activities of daily living. R1 was also diagnosed with dementia. Per review of records and interviews, the placement agency for the resident had not been told of the residents behaviors of any aggressiveness and wandering. The Licensee stated to the LPA that she was not provided any information or made aware of R1's aggressive behavior which was both verbal and physical, and of the resident's wandering behavior when speaking with the resident's responsible party for placement in the facility. Licensee stated that she had set up group meeting to try and address the incidents arising after the placement of R1 into the facility.

Licensee stated that the resident would get confused and angry, yelling and striking out at staff using their hands and kicking with their feet; The resident broke items in the facility by throwing and smashing them when angry. The resident would leave out of the front door stating they were leaving. Staff would follow R1 when able, and always contacted 911, and the Licensee. Licensee would contact responsible party. The police were contacted to help in getting the resident back to the facility safely. Licensee stated that she had requested help from Police in taking R1 in for medical evaluation after an incident of an AWOL and aggressiveness to staff but no POA consent was given so R1 was not taken to the hospital. Staff had notified the POA, and the Physician of incidents occurring with residents behaviors. R1's medications were reviewed and the Physician prescribed medication with specific dosage information. The resident AWOL the facility a total of four times, once on 4/28, once on 4/29, and twice on 5/8. Facility contacted 911/Police, and responsible party/POA on the incidents. The facility is able to care for dementia residents, the facility has exit door auditory alarms that go off to alert staff when a door is opened. The facility is not fire cleared approved to have a locked perimeter. Resident's needs were being met per interviews and record reviews but the concern was resident's anger/aggressiveness and AWOLs from the facility. Per the investigation the facility was providing care and supervision to R1, and following the plan of operation regarding policies of AWOLs.
Continued on LIC9099C....

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200508171851

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: WILLOW GLEN HOME	FACILITY NUMBER: 496803796
	VISIT DATE: 09/16/2020

NARRATIVE

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Per the investigation, it was revealed the facility does have policies to address AWOL incidents, and these were being followed by staff; The Licensee had addressed each incident with the POA, the resident's Physician, and resident's needs were being met; The behaviors of AWOL and R1's aggressive behavior were being discussed with the POA, and R1's other family members to review care plan for resident. including and addressing behaviors. It was decided by POA that they were going to move the resident out of the facility as soon as possible due to their behaviors, and possibly finding a facility with a locked perimeter.

Based on the investigation, there is no evidence to support the allegations were violated. The allegations of residents needs are not being met, and facility safety measures are not addressing resident's behaviors are 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.
No deficiencies cited today.
Exit interviews conducted.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2020

LIC9099 (FAS) - (06/04)

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