496803864-11-30-2021-21-AS-KMOA-C9GPTC-20211207103540

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803864
Report Date: 11/30/2021
Date Signed: 11/30/2021 12:25:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2021 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20211013090631

FACILITY NAME:	SONOMA OAK TREE HOME		FACILITY NUMBER:	496803864
ADMINISTRATOR:	ROWLANDS, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	425 ARBOR AVE		TELEPHONE:	(707) 287-6214
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	6	CENSUS: 6	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Christina Rowlands		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident(s) are being over medicated
Staff do not assist residents with incontinence needs
Staff unable to meet residents' care needs
Staff are unable to meet hygiene needs for residents

INVESTIGATION FINDINGS:

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

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the findings. During the course of this investigation, statements were taken, site visits made, and records were obtained and reviewed. Based upon those records and statements, the following determinations are made: Complainant alleges staff leave residents in dirty clothes and do not attend to incontinent needs and that Administrator overmedicates residents by administering other residents' medication to some residents; Site visits to facility indicate residents are clean and appropriately dressed; medication reviews have revealed issues but do not prove overmedication of residents; Family members of the residents were contacted and all, without exception, were satisfied with their loved ones care and had no complaints that would suggest the noted allegations to be valid; Staff that were interviewed made positive statements regarding the facility and did not agree with complainant's allegations. Although the allegations may be true, based upon the interviews, records, and site visits, the preponderance of evidence standard has not been met. Therefore, the allegations are UNSUBSTANTIATED.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/13/2021 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20211013090631

FACILITY NAME:	SONOMA OAK TREE HOME		FACILITY NUMBER:	496803864
ADMINISTRATOR:	ROWLANDS, CHRISTINA		FACILITY TYPE:	740
ADDRESS:	425 ARBOR AVE		TELEPHONE:	(707) 287-6214
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	6	CENSUS: 6	DATE:	11/30/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Christina Rowlands		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Medication was inappropriately stored/dispensed

INVESTIGATION FINDINGS:

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

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Administrator and discussed the findings. During the course of this investigation, records were reviewed, medication audit conducted, statements taken, and site visits made. Based upon the audit, records, and statements, the following determinations are made: Complainant alleges that the Administrator has altered medication containers and dispensed other residents medication to residents; Administrator states that the altered medication containers were altered by family member of R2 as a self reminder for administering at proper times; Family member of R2 does not recall but has indicated it is likely true or possible; medication audit on 10/26/2021 revealed that medication container for R3 should have contained 129 tabs but only contained 100; Administrator stated that she removed 29 tabs from the container and stored them in separate container. Based upon the administrator’s statement and the medication audit, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20211013090631

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SONOMA OAK TREE HOME	FACILITY NUMBER: 496803864
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/07/2021 Section Cited CCR 87465(h)(5)	1 2 3 4 5 6 7	87465(h)(5) Incidental Medical and Dental Care. Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. Based upon statement and audit, this requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administrator will review 87465 and submit a signed and dated declaration attesting to same and pledging to follow the requirements of the regulations. Declaration to be submitted to CCL by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	Administrator removed 29 tabs from medication container and stored them in another container. This posed a potential risk to the health 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.

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3