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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803820
Report Date: 02/02/2024
Date Signed: 02/02/2024 12:55:31 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
12/21/2023 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20231221142319
FACILITY NAME:ENSO VILLAGE, A KENDAL AFFILIATEFACILITY NUMBER:
496803820
ADMINISTRATOR:JORDAN, ROSEMARYFACILITY TYPE:
741
ADDRESS:1801 BOXHEART DRIVETELEPHONE:
(925) 366-3414
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:138CENSUS: 111DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nestor Mendez, VP of OperationsTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee does not ensure facility grounds are free from hazards
Facility is not providing a comfortable environment
INVESTIGATION FINDINGS:
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At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager, (LPM) Victoria Bertozzi arrived at this facility unannounced, to deliver findings regarding a complaint investigation into the above allegations. LPA and LPM met with VP of Operations, Nestor Mendez and Rosemary Jordan, CEO.

Licensee does not ensure facility grounds are free from hazards - Complaint alleges that facility has a drainage problem on the facility grounds which is causing multiple large pools of water to collect and cover resident walkways outside. During the 12/29/2023 visit, CCL staff observed accessible "bioswales" which are defined areas of landscaping that drop down to create a pool. Not all were fenced to mitigate risk on 12/29/2023. LPA and LPM confirmed through observation on 12/29/2023 and 2/2/2024 that there are other areas of concern that are hazardous including but not limited to construction debris, accessibility to the car barn and compactor and an area of the facility that collects water.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 5
Control Number 21-AS-20231221142319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: ENSO VILLAGE, A KENDAL AFFILIATE
FACILITY NUMBER: 496803820
VISIT DATE: 02/02/2024
NARRATIVE
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Continued from 9099...

Facility is not providing a comfortable environment - Complaint alleges that facility elevators in all ten buildings are not operational. Additionally, residents are having issues with HVAC fans in their private rooms that run all the time and cannot be manually turned off, which allows cold air to flow in from outside. Per complaint, the HVAC system makes a loud whistle/whirring noise, causing some residents to not be able to sleep. Also, the thermostats in most rooms are not working or are too complex for residents to operate, resulting in residents not having heat in their rooms. Some were provided with temporary space heaters. LPA and LPM confirmed through the staff interviews on 12/29/2023 that the HVAC in Meadows building does have sound issues and that the problem was identified as being due to insufficient springs on the roof. It was communicated to CCL staff on 12/29/2023 that the HVAC springs are on order and the facility is waiting for the shipment to arrive. Per staff interview conducted today, the springs have not arrived and there is not estimated time of arrival for the springs. The sound issues have been present since the residents moved in.
The temperature in residents units is a known issue. Per staff interview some units are still having issues with temperature, however the facility have provided space heaters for some and installed a more traditional heating thermostat to work in conjunction with existing thermostat, in order to mitigate thermostat error.

Based on LPA and LPM observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division & Chapter number, are being cited on the attached LIC 9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
12/21/2023 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20231221142319

FACILITY NAME:ENSO VILLAGE, A KENDAL AFFILIATEFACILITY NUMBER:
496803820
ADMINISTRATOR:JORDAN, ROSEMARYFACILITY TYPE:
741
ADDRESS:1801 BOXHEART DRIVETELEPHONE:
(925) 366-3414
CITY:HEALDSBURGSTATE: CAZIP CODE:
95448
CAPACITY:138CENSUS: 111DATE:
02/02/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nestor Mendez, VP of OperationsTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee advertises amenities that are not available to residents.
Licensee does not ensure residents receive contracted services.
Licensee does not abide by the terms of residents’ admission agreements.
INVESTIGATION FINDINGS:
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At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo and Licensing Program Manager, (LPM) Victoria Bertozzi arrived at this facility unannounced, to deliver findings regarding a complaint investigation into the above allegations. LPA and LPM met with VP of Operations, Nestor Mendez.

Licensee advertises amenities that are not available to residents, Licensee does not abide by the terms of residents’ admission agreements, Licensee does not ensure residents receive contracted services - Complaint alleges that per the terms of the admission agreements, amenities should be available and because they aren't, the facility is in violation of the Admission Agreement. Per CCL review of the Continuation Care Statutes, there is not a violation of the terms. Some amenities and services are delayed due to construction and functionality issues but do have planned completion dates.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
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 5
Control Number 21-AS-20231221142319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ENSO VILLAGE, A KENDAL AFFILIATE
FACILITY NUMBER: 496803820
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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Facility to provide written plan of how noted areas will be addressed to mitigate risk to all residents in care. Facility to submit plan to specify how facility will mitigate identified risks. Faclity to submit plan by plan of correction due date of 2/9/2024.
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Based on CCL observation facility has accessible "bioswales" pools, some of which were not fenced. Other observed hazards include: construction debris and accessibility to: car barn, compactor and an area of the facility that collects water. This poses a potential risk to health and safety.
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Type B
02/09/2024
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all RCFEs shall have all of the following personal rights: (2)To be accorded safe, healthful & comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on CCL interview
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Facility provide update regarding HVAC system and how they will mitigate noise created. Facility to provide plan of how they will ensure residents' apartments are able to maintain a comfortable temperture.
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with staff and observations, there are issues with heating and noise which poses a potential risk topersonal rights.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5