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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803860
Report Date: 09/26/2023
Date Signed: 09/26/2023 07:51:00 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
09/19/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230919134801
FACILITY NAME:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR:O'SULLIVAN, JANNAFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESSWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:114CENSUS: DATE:
09/26/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Janna O'Sullivan-AdministratorTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Resident not allowed to use facility phone and/or receive calls
Resident is not allowed visitors
Resident is not allowed to leave the facility



INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/26/2023 at approximately 9:00am, and met with Administrator Janna O'Sullivan, H&W Director Janice Foster, and Memory Care Director Monica Hernandez. LPA reviewed resident(R1) records, and facility records. LPA conducted interviews with staff, S1, S2, S3, and conducted interviews with other related parties.

The investigation revealed that per record reviews, and interviews, the resident (R1) is allowed to use the phone to make calls if wanted. There is a phone in the medical staff office that may be used by resident(s) when wanted. Administrator stated that there is a cordless phone that may be used by residents if wanted. Staff can provide the resident(s) with a phone to make a call.

Staff interviewed stated that if a call comes into the facility for a resident they will notify the resident of the call so the resident may take/receive the call. Investigation revealed that R1 is allowed visitors, and the log of R1's visits was provided to the LPA for review.
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
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-20230919134801
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: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860
VISIT DATE: 09/26/2023
NARRATIVE
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Per record reviews, R1 does have a Power of Attorney (POA) due to resident's diagnosis, to ensure appropriate resident care, supervision, and health and safety. Resident is allowed off facility premises for facility outings/activities, medical appointments, and with family members; Per interviews with staff, and other related parties, the POA is involved in decisions of the resident leaving the property due to resident's need for care and supervision at all times. Resident is not allowed into the community on their own per medical assessment, per file review. Resident is allowed to have visitation, during visiting hours, with family and friends when wanting to and/or when visitors arrive to see the resident.

Per record reviews, currently there is a restraining order in place, effective 9/8/23, which expires 9/29/23.The facility will follow the restraining order as required. Per staff interviews, the facility is following the restraining order in place by the court.

The investigation found that there was differing information from interviews conducted, records reviewed, and information provided by the reporting party. There was no information obtained to support a violation had occurred regarding the allegations.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "Resident not allowed to use facility phone and/or receive calls, Resident is not allowed visitors, Resident is not allowed to leave the facility" are Unsubstantiated, meaning that although the allegations 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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
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
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
09/19/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230919134801

FACILITY NAME:CLEARWATER AT SONOMA HILLSFACILITY NUMBER:
496803860
ADMINISTRATOR:O'SULLIVAN, JANNAFACILITY TYPE:
740
ADDRESS:710 ROHNERT PARK EXPRESSWAY ETELEPHONE:
(707) 710-7385
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:114CENSUS: DATE:
09/26/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Janna O'Sullivan-AdministratorTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Resident is not provided personal privacy
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/26/2023 at approximately 9:00am, and met with Administrator Janna O'Sullivan, H&W Director Janice Foster, and Memory Care Director Monica Hernandez. LPA reviewed resident(R1) records, and facility records. LPA conducted interviews with staff, S1, S2, S3, and conducted interviews with other related parties.

The investigation revealed that per record reviews, and interviews, R1 was not allowed to have a private visit in their room with a visitor. R1's room was locked, and kept locked, room was kept inaccessible to the resident during R1's visit with a friend. Per staff interview with S3, they were instructed that R1 was not to have private visiting in their room, and the resident's R1's room would need to be kept locked during their visit with a friend. R1 was denied a private visitation with a friend.

Per record reviews, currently there is a restraining order in place, effective 9/8/23, which expires 9/29/23.The facility will follow the restraining order as required. Per staff interviews, the facility is following the restraining order in place by the court as of 9/8/23.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
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-20230919134801
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: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860
VISIT DATE: 09/26/2023
NARRATIVE
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Resident's is allowed visitors, and a private visit if wanted. R1's personal rights were violated when facility staff denied the resident a private visit with a visiting friend.

Due to the substantiation of the allegation, a citation, 87468.1(a)(11) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon, will be cited today, see LIC9099D.

Based on LPA interviews, review of records, and information LPA obtained, the investigation has revealed that the allegation of "Resident is not provided personal privacy" is substantiated.

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.
Appeal Rights Given.
Exit interview conducted with the Administrator Janna O'Sullivan.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230919134801
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: CLEARWATER AT SONOMA HILLS
FACILITY NUMBER: 496803860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2023
Section Cited
CCR
87468.1(a)(11)
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87468.1(a)(11) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
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Licensee/Administrator to have an in-service training with all staff regarding "residents personal rights" and that staff are to not violate these rights at any time. Proof of training to include, Trainer, Topics, Date/Time Spent and Attendees.
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This requirement was not met as evidenced by: Per interviews with staff, and review of records, staff were instructed that R1 was not to have private visiting in their room, and the resident's R1's room would need to be kept locked during their visit with a friend. R1 was denied a private visit with a friend. This is a risk to resident's personal rights.
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Submit plan of correction, and proof of training by POC due date of 10/13/23.
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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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5