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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803820
Report Date: 03/06/2024
Date Signed: 03/06/2024 10:45:42 AM

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
01/31/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240131130354
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: 141DATE:
03/06/2024
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Nestor Mendez, VP of Operations and Rosemary Jordan, CEOTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Residents are inhabiting area(s) of the facility that do not have a fire clearance
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.

Residents are inhabiting area(s) of the facility that do not have a fire clearance – Complaint alleges that residents are inhabiting area(s) of the facility that do not have a fire clearance. On 1/31/2024 CCL received notification that a witness observed a resident on the 2nd floor (G wing) in their unit after hours, specifically at 9:09 PM. This observation was documented with a photograph. Per review of email communication from the Healdsburg Fire Dept Fire Marshal to Enso’s CEO Rosemary Jordan, no individuals were to be in the areas lacking fire clearance outside of business hours.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
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 3
Control Number 21-AS-20240131130354
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: 03/06/2024
NARRATIVE
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continued from 9099...

During 2/2/2024 visit, CCL staff toured rooms located on the 2nd floor in the G wing which were not fire cleared. CCL observed items such as an opened sleeping bag on top of tri-fold mattress which appeared slept in, medications including over the counter prescriptions, a weekly pill organizer with pills present, toothbrushes, toothpaste, tongue scraper, mouthwash, body wash, shampoo and shower squeegee as well as refrigerator stocked with perishable food and waste baskets full of perishable food waste. CEO, Rosemary Jordan, indicated that items such as toothpaste were used for good daytime oral hygiene and mattresses used for a brief rest during the hours of 8am-5pm. Per letter received by CCL on 2/26/2024 from facility a resident was confirmed in their unit after 9:00pm but facility considers it an isolated incident.

Based on 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 VP of Operations and a copy of this report was given.


SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240131130354
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: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/13/2024
Section Cited
CCR
87203
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87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as eveidence by:
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Area identified now have a fire clearance. Facility to submit self-certification that remaining areas that have not yet received a fire clearance will be entered only as permitted by the fire department. Occupancy requires approval by CCL. Plan of Correction due no later than 3/11/2024.
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Based on observation and review of photo, the licensee did not meet this requirement by resident being observed in a non fire cleared room after the hours designated by the Fire Dept. This is a potential risk to health and safety of residents.
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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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3