496803828-6-24-2022-21-AS-KMOA-CGBM6X-20220714092041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803828
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:45:08 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
03/21/2022 and conducted by Evaluator Erik Gonzalez Campos

COMPLAINT CONTROL NUMBER: 21-AS-20220321112143

FACILITY NAME:	RINCON VALLEY GUEST HOME		FACILITY NUMBER:	496803828
ADMINISTRATOR:	POPAT, SABRINA		FACILITY TYPE:	740
ADDRESS:	996 ESTES DR		TELEPHONE:	(707) 539-6247
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95409
CAPACITY:	6	CENSUS: 4	DATE:	06/24/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Staff, Marlene Guido		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Neglect/lack of supervision resulted in resident with unexplained injury
Neglect/lack of supervision resulted in staff not seeking timely medical attention for residents change in medical condition
Neglect/lack of supervision resident needs are not being met
Administrator failed to report incidents timely

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 06/25/2022 and met with staff, Marlene Guido for the purpose of delivering findings regarding the above allegations.

There is an allegation of neglect/lack of supervision resulted in resident with unexplained injury. LPA conducted interviews and reviewed documents. Review of hospice documents revealed that the injuries were various bruises and skin tears. Record review revealed that injuries were documented, and conversations were had between facility, hospice, and resident’s responsible party. LPA was unable to identify any concerns of neglect or lack of supervision. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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-20220321112143

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: RINCON VALLEY GUEST HOME	FACILITY NUMBER: 496803828
	VISIT DATE: 06/24/2022

NARRATIVE

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The is an allegation of neglect/lack of supervision resulted in staff not seeking timely medical attention for residents change in medical condition. LPA reviewed hospice documents and conducted interviews with facility staff. Documentation shows frequent health aide visits, and nurses visits between 01/01/2022-03/21/2022. LPA was unable to identify any concerns of neglect or lack of supervision. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation of neglect/lack of supervision resident needs are not being met. LPA conducted resident interviews and toured the facility. Residents indicated to LPA that their needs are being met in 2 out of 2 resident interviews. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that administrator failed to report incidents timely. LPA conducted interview with facility staff and administrator as well as reviewed documents. LPA did not find anything to indicate that incidents were not reported timely. Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with Marlene Guido and a copy of this report printed for the facility.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez Campos	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC9099 (FAS) - (06/04)

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