496803860-10-3-2024-21-AS-BMOS-D9VMUY-20241009095553

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803860
Report Date: 10/03/2024
Date Signed: 10/03/2024 05:43:13 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
06/04/2024 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240604084835

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: 94	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	James Homer - Executive Director		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Lack of supervision resulted in resident sustaining an unwitnessed fall
Staff are not assisting resident with incontinence care and/or assisting resident with a toileting schedule
Staff are not ensuring resident(s) has clean clothing
Staff are not assisting resident(s) with hygiene care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 10/3/2024 at approximately 9:00am, and met with Executive Director James Homer, and Health Services Director/LVN Janice Foster.

LPA reviewed resident (R1) records, including medical documentation, and facility records. LPA conducted interviews with staff (S2, S3, S4, S5), and with other related parties. LPA obtained conflicting information regarding allegations of "lack of supervision resulted in resident sustaining an unwitnessed fall, staff are not assisting resident with incontinence care and/or assisting resident with a toileting schedule, staff are not ensuring resident(s) has clean clothing, staff are not assisting resident(s) with hygiene care". Per record reviews and interviews, the investigation revealed that R1 had a care plan in place, and the resident was on a shower schedule, and a laundry schedule. R1 would be offered their shower multiple times, and most times they could get them to shower, even if being combative about it. When resident continued to refuse a shower, it would be noted, and followed up on the next shift and/or shower provided the next day. Hygiene care, including showering, brushing teeth, cleaning/grooming as needed for a resident. Per review of records,

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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-20240604084835

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: CLEARWATER AT SONOMA HILLS	FACILITY NUMBER: 496803860
	VISIT DATE: 10/03/2024

NARRATIVE

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R1 was provided hygiene care regularly, including brushing their teeth, cleaning their face/body as needed. Per review of records, and staff interviews, R1 was toileted and cleaned and changed as needed, every one-two hours minimum, most times every hour. Soiled clothing and linens are to be taken to the laundry room daily and washed; Besides the washing machines in the memory care unit, staff also uses the two larger laundry rooms in the main facility, in assisted living as needed. All other dirty laundry is done weekly per the schedule. If laundry is done by a family member/responsible party staff stated it is by their choice, it is not required of them. Per record reviews, R1 had two (2) unwitnessed falls, on 1/3/24 & 4/29/24. No serious injuries sustained after assessments were done by staff. R1 was not a one to one staffed resident; R1 can ambulate on their own when wanting to, and residents are not restrained in assisted living and/or memory care from moving about freely. Staff provide checks on resident's in their rooms as needed. Staff supervise and monitor groups of residents as needed, and only residents that are one to one have a staff with them at the specified times per their care plans.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations "lack of supervision resulted in resident sustaining an unwitnessed fall, staff are not assisting resident with incontinence care and/or assisting resident with a toileting schedule, staff are not ensuring resident(s) has clean clothing, staff are not assisting resident(s) with hygiene care” are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Executive Director James Homer.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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