496803796-1-4-2022-21-AS-HDBI-CB94GC-20220201180519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803796
Report Date: 01/04/2022
Date Signed: 01/04/2022 09:55:22 AM

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
12/13/2021 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20211213105957

FACILITY NAME:	WILLOW GLEN HOME		FACILITY NUMBER:	496803796
ADMINISTRATOR:	HUNTER, GINA		FACILITY TYPE:	740
ADDRESS:	4750 COUNTRY CLUB DR		TELEPHONE:	(707) 708-2199
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	6	CENSUS: 6	DATE:	01/04/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Miguelina Hernandez		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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7
8
9

Night staff does not adequately document medication logs

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegation. LPA met with Ms. Hernandez and Licensee (by phone). Complainant states that Complainant was told by a staff member that the night staff do not document medication logs. During the course of this investigation, statements have been taken; documents obtained and reviewed; site visits made. The following determinations have been made: Administrator and staff who were available for interview state that medications are typically given by staff other than night staff and that, until recently, PRN medication has not been administered at night; records reviewed support the statements made by staff and Administrator. A Medication Administration Record has not been utilized by the facility and, consequently, is not available to review. While the allegation may be true, or valid, based upon the statements and documents, there is not a preponderance of evidence to prove the allegation is or, is not, true. Therefore, the allegation is UNSUBSTANTIATED.

No citations issued. Copy of report left at facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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 3

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
12/13/2021 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20211213105957

FACILITY NAME:	WILLOW GLEN HOME		FACILITY NUMBER:	496803796
ADMINISTRATOR:	HUNTER, GINA		FACILITY TYPE:	740
ADDRESS:	4750 COUNTRY CLUB DR		TELEPHONE:	(707) 708-2199
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	6	CENSUS: 6	DATE:	01/04/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Miguelina Hernandez		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not adequately trained

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegation. LPA met with Ms. Hernandez and Licensee (by phone). Complainant states that Complainant was told by a staff person that S1 and possibly other staff have not been trained on medications; First Aid; CPR and other required training. During the course of this investigation, statements have been taken; documents obtained and reviewed; site visits made. The following determinations have been made: Complainant declined to provide contact information; Training hours for S1 are up to date, including Medication, CPR, and First Aid; One out of three staff training audits indicates that S2 did not receive 7 hours of the initial 40 hours of required training. Based upon the statements taken and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

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 3

Control Number 21-AS-20211213105957

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/18/2022 Section Cited HSC 1569.625(b)(1)	1 2 3 4 5 6 7	1569.625(b)(1) Staff Training. 40 hours (with some specified areas) required before working independently with residents…completed within first 4 weeks of employment. Based on file review and statements, this requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee to insure that all new staff will receive 40 hours of initial training as required. Licensee to submit 40 hours of training for S2 and a written plan for staff training by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	S2 hired in July 2021 and did not complete initial training (33 of 40) hours. This poses a potential risk to the safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC9099 (FAS) - (06/04)

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