496803905-7-3-2024-21-AS-BMOS-D9FTSB-20240925145846

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803905
Report Date: 07/03/2024
Date Signed: 07/03/2024 05:40:46 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
03/25/2024 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240325160332

FACILITY NAME:	ARBOL RESIDENCES OF SANTA ROSA		FACILITY NUMBER:	496803905
ADMINISTRATOR:	TA, HANH		FACILITY TYPE:	741
ADDRESS:	300 FOUNTAINGROVE PARKWAY		TELEPHONE:	(707) 566-8600
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	152	CENSUS: 94	DATE:	07/03/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Karina Tapia-Interim Admnistrator		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Facility is in disrepair
Resident room has a bad odor
Staff did not provide a safe and comfortable environment for resident
Staff are not properly supervising residents who may be a fall risk

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a complaint investigation, on 7/3/24 at approximately 12:15pm, and met with Interim Administrator Karina Tapia, who is the facility's Health & Wellness Director. There are scheduled days and hours during the week that the HWD covers the Administrator position, till filled. HWD does have an active administrator certificate.

LPA reviewed records on resident R1, including medication records. LPA conducted interviews with staff, and other related parties. The investigation revealed that R1's room was observed to be clean and orderly at the time of inspection. The bathroom was checked and was free of urine odor. Administrator stated that they had been cleaning and doing some repairs to the resident bathroom. LPA observed no odor and/or disrepair at time of inspection to the resident room and bathroom. Resident R1 was not a one to one care need, no one to one staff, per review of care plan, and interviews with staff and other related parties. Resident was monitored as needed per care plan and as observed by staff, per interviews.
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: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

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-20240325160332

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: ARBOL RESIDENCES OF SANTA ROSA	FACILITY NUMBER: 496803905
	VISIT DATE: 07/03/2024

NARRATIVE

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There was no medical documentation of resident R1 having a sit-down fall when transitioning from walker to their dining room seat due to weakness of their health condition; R1 had no injury noted and/or documented from a sit-down fall. Per interviews, and record reviews, there were no records, information and/or documentation of staff not speaking appropriately to the resident, and/or not providing services with dignity and respect to R1. There was no information obtained in review of records, and interviews that supported violations occurred regarding the listed allegations.

Based on the Department's investigation, interviews, observations, and review of records, the allegation of "Facility is in disrepair, Resident room has a bad odor, Staff did not provide a safe and comfortable environment for resident, Staff are not properly supervising residents who may be a fall risk" are unsubstantiated.

Although the allegation(s) may have happened or is valid, there is not a preponderance
of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated.

No deficiencies/citations during today’s visit.
Exit interview was conducted with the Executive Director Marcus Strohschein.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2024

LIC9099 (FAS) - (06/04)

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