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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803796
Report Date: 12/08/2022
Date Signed: 12/08/2022 04:56:05 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
09/16/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220916155249
FACILITY NAME:WILLOW GLEN HOMEFACILITY NUMBER:
496803796
ADMINISTRATOR:HUNTER, GINAFACILITY TYPE:
740
ADDRESS:4750 COUNTRY CLUB DRTELEPHONE:
(707) 708-2199
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 6DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
04:18 PM
MET WITH:Licensee Zoe TeeterTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff failed to give medication as prescribed.
Staff are handling residents in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection to deliver findings. LPA met with Administrator Inez Florez, and Licensee Zoe Teeter. There were six(6) clients in care at the facility during the complaint inspection. Upon LPA's arrival there was one caregiver Rosa Orantes on shift. Caregiver contacted the Licensee Zoe Teeter, who arrived to the faciity with the Administrator a short time later.

The LPA reviewed records of residents and staff, and obtained copies. The LPA interviewed staff, and other interested parties, regarding the allegations; The complaint investigation by the Department revealed that there was no sufficient evidence to prove violations occurred.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
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 2
Control Number 21-AS-20220916155249
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: WILLOW GLEN HOME
FACILITY NUMBER: 496803796
VISIT DATE: 12/08/2022
NARRATIVE
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There were no named and/or identified residents that were not receiving medications as prescribed per reported information; Investigation didn't identify/find evidence from record reviews that residents had received medications not as prescribed. All staff had required training per record reviews, medication and care giver training, including transfer of residents training.

Based on the investigation, there is no evidence to support the allegations were violations. The allegations of "staff failed to give medication as prescribed, and staff are handling residents in a rough manner ' 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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2