496803853-8-6-2025-21-AS-CMAZ-DN97MJ-20251108204713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803853
Report Date: 08/06/2025
Date Signed: 08/06/2025 01:08:46 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
07/07/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250707142039

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: 5	DATE:	08/06/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Monicah Gacegu-Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not submit required reports to the licensing agency

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

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 4

Control Number 21-AS-20250707142039

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: 08/06/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099, dated 8/6/2025..

Per review of hospital records provided to the LPA, R1 went out by 911 to the hospital on 12/19/23 for abdominal pain, 3/23/2024 for a fall resulting with a head injury, and on 5/27/25 for a fall resulting in a fracture. Resident had been hospitalized and receiving medical care for the fracture; Resident passed in the hospital 6/2025.

Per facility file review, and department record review, there were no written reports to the Department regarding the above listed dates of resident incidents, 12/19/23, 3/23/24, and 5/27/25, including a report of the passing of R1, 6/2025, as required. There was sufficient information obtained to support that a violation had occurred regarding the allegation.

The investigation, review of records, and interviews with staff, and other parties, finds that the facility failed to report incidents to the department as required by regulation. This deficiency will be cited, Reporting Requirements 87211(a)(1)- Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D). This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case, see LIC9099.

The LPA reviewed regulation 87211 Reporting Requirements, with the Licensee/Administrator Monicah,Gacegu, and the importance of compliance with this regulation at all times. Licensee/Administrator stated their understanding of the above.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with the Administrator Monicah Gacegu.
Appeal Rights Provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
07/07/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250707142039

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: 5	DATE:	08/06/2025
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Monicah Gacegu-Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained injury due to lack of care from staff

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/6/25 at approximately 9:40am, and met with Administrator Monicah Gacegu.
Reporting party alleges that "resident sustained injury due to lack of care from staff". LPA reviewed resident (R1) records, including admission documents, medical assessment/diagnosis, medication records, and medical documentation. LPA reviewed hospital records obtained during the investigation regarding R1 and incidents that occurred. LPA conducted interviews with staff and other related parties.
The investigation revealed R1 was admitted 11/7/2023. Per review of medical records assessment, resident was a fall risk, and used a walker for help with mobility. Per record reviews, and interviews with staff, S1 and S2, resident (R1) was assisted with care needs, and ambulating in the facility, ensuring resident used their walker, with staff assisting as needed. R1 did have two falls and staff contacted 911 on these incidents, as needed to have resident assessed by a medical professional. R1 had an incident of abdominal pain and staff contacted 911 fo have the resident assessed by a medical profssional. The Department received no reports of suspected neglect of R1's care needs/of R1 from hospital medical Physician (s) regarding the above incidents, and assessmemts of the resident at the time of these incidents/at any time.There was no information obtained to support that a violation had occurred regarding the allegation.Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "resident sustained injury due to lack of care from staff” is Unsubstantiated, meaning that although the allegation 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

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 4

Control Number 21-AS-20250707142039

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/07/2025 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Reporting Requirements 87211(a)(1)- Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D). This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case, This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator to ensure to procide the written incident reports of 12/19/23, 3/23/24, 5/27/25, and death report of 6/2025. Submit plan of future compliance with this regulation. POC due 8/7/2025.
	8 9 10 11 12 13 14	Per facility file review, and department record review, and interviews, there were no written reports to the Department as required, regarding resident incidents, 12/19/23, 3/23/24, and 5/27/25, including a report of the passing of R1, 6/2025. This is a risk to health & safety of residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4