496803853-9-9-2024-21-AS-BMOS-D9VN78-20241009101218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803853
Report Date: 09/09/2024
Date Signed: 09/09/2024 05:42:16 PM

Unsubstantiated

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
04/08/2024 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240408145051

FACILITY NAME:	MOGRACE RESIDENCE		FACILITY NUMBER:	496803853
ADMINISTRATOR:	GACEGU, MONICAH		FACILITY TYPE:	740
ADDRESS:	6299 COUNTRY CLUB DRIVE		TELEPHONE:	(707) 843-7884
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	8	CENSUS: 6	DATE:	09/09/2024
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Fridah Kipsenal-Caregiver		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff are not providing care needs to residents
Staff leaves residents in bed for extended periods
Staff are not providing activities for residents in care
Staff are speaking inappropriately to the resident
Staff leaves residents unattended

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/9/24 at approximately 1:20pm, and met with caregiver Fridah Kipsenal. LPA spoke with Licensee/Administrator Monicah Gacegu regarding the inspection being conducted today; Licensee/Administrator notified the LPA they were not available to come to the facility at this time, but to call if anything is needed.

There are six (6) residents residing in the facility. LPA reviewed six (6) resident records; The LPA requested copies of records. Administrator provided the requested copies to the LPA. LPA reviewed records, and conducted interviews with staff and other related parties. The investigation revealed that R1 moved into the facility per ecord reviews, on 3/9/2024. Resident (R1) is conserved by two (2) conservators, one for the estate, and one for the care of the resident/living situation of the resident. Per interviews with staff, residents needs are met, Incontinent care is being provided as needed and required for all residents that are incontinent, per S1.

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

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-20240408145051

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: MOGRACE RESIDENCE	FACILITY NUMBER: 496803853
	VISIT DATE: 09/09/2024

NARRATIVE

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R1's needs are met, and resident is provided care services per care plan,Per interviews with staff, the residents are assisted out of bed and brought out of their rooms to the dining table and/or the living room. If a resident says no to getting out of bed, the staff will try again after a few minutes. The residents will usually get up and out of bed for awhile throughout the day as wanted. Staff stated they don't neglect the residents, the residents are cared for. Staff stated that they do activities with the residents getting them up from bed, grooming, feeding, medications, activities and hygiene care. R The facility does have a dementia plan of operation, and is able to care for dementia residents. Interviews with staff, and other related parties, revealed that there are activities offered, and some residents will join in if wanting to. Staff deny that they speak inappropriately to residents in care; Interviews with other related parties, stated the staff don't speak inappropriately to residents. Staff S1 stated they have never left the facility unattended, there is always a staff working. S1 stated they deny ever having left the facility with no staff at any time. The interviews and record reviews didn't provide information that supported violations had occurred regarding the allegations.

Per interviews with one of the Conservators, the care home was an emergency placement for R1, and resident was to move out to another facility when it became available. R1 transferred out 5/17/24 to a new facility.

It was found that there is differing information obtained in the investigation regarding the allegations that
"staff are not providing care needs to residents, staff leaves residents in bed for extended periods, staff are not providing activities for residents in care, staff are speaking inappropriately to the resident, staff leaves residents unattended". There was no information obtained that supported that a violation had occurred.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations are/is Unsubstantiated, meaning that although the allegation (s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Administrator Monicah Gacegu.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024

LIC9099 (FAS) - (06/04)

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