496803860-9-26-2023-21-AS-VBEI-CZUPUT-20240126103800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803860
Report Date: 09/26/2023
Date Signed: 09/26/2023 07:44:57 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
09/25/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230925135806

FACILITY NAME:	CLEARWATER AT SONOMA HILLS		FACILITY NUMBER:	496803860
ADMINISTRATOR:	O'SULLIVAN, JANNA		FACILITY TYPE:	740
ADDRESS:	710 ROHNERT PARK EXPRESSWAY E		TELEPHONE:	(707) 710-7385
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	114	CENSUS:	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Janna O'Sullivan-Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff hit resident with an object

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. LPA reviewed two (2) staff files. LPA conducted interviews with staff, S1, S2, S3, S4, and other related parties. The investigation revealed that staff, S4, denied hitting the resident at any time, and denied hitting the resident with an obbject. R1 was assessed by the Admnistration staff after the allegation was reported, and resident was observed to have no injuries, and R1 was observed to be at their baseline. Per staff records reviewed, staff has required trainings. The investigation found that there was different information from interviews conducted, and information provided by the reporting party. There was no information obtained to support a violation had occurred regarding the allegation. Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegation "staff hit resident with an object" is 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (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)

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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
09/25/2023 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230925135806

FACILITY NAME:	CLEARWATER AT SONOMA HILLS		FACILITY NUMBER:	496803860
ADMINISTRATOR:	O'SULLIVAN, JANNA		FACILITY TYPE:	740
ADDRESS:	710 ROHNERT PARK EXPRESSWAY E		TELEPHONE:	(707) 710-7385
CITY:	ROHNERT PARK	STATE: CA	ZIP CODE:	94928
CAPACITY:	114	CENSUS:	DATE:	09/26/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Janna O'Sullivan-Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff speaks inappropriately in the presence of residents

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (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)

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Control Number 21-AS-20230925135806

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 B 10/13/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4) Additional Personal Rights of Residents- In addition to the rights in Section 87468.1, Personal Rights of Residents:To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers qualifications, and competency to meet their needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	Per investigation, S4, has been wriiten up, on 7/11/23, by Administration staff for speaking inappropriately to a resident.The documentation was provided to the LPA. The LPA interviewed the above staff; including S4 who confirmed the incident, and confirmed having spoken to a resident inappriately at that time. This is a risk to residents personal rights and/or a risk to resident's health& safety.	8 9 10 11 12 13 14	Submit plan of correction, and proof of training by POC due date of 10/13/23.
	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.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (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)

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Control Number 21-AS-20230925135806

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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Due to the substantiation of the allegation, a citation, 87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, 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 "Staff speaks inappropriately in the presence of residents" 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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (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)

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