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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803905
Report Date: 08/22/2024
Date Signed: 08/22/2024 04:34:16 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
COMPLAINT CONTROL NUMBER: 21-AS-20240325160332
FACILITY NAME:ARBOL RESIDENCES OF SANTA ROSAFACILITY NUMBER:
496803905
ADMINISTRATOR:TA, HANHFACILITY TYPE:
741
ADDRESS:300 FOUNTAINGROVE PARKWAYTELEPHONE:
(707) 566-8600
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:152CENSUS: DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Karina Tapia-Interim AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff are mismanaging residents' medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a complaint investigation, on 8/22/24 at approximately 9:15am, and met with Interim Administrator Karina Tapia, who is the facility's Health & Wellness Director (HWD). 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 per record reviews, R1's medications were being provided as ordered. Some medications due to labs performed, would be discontinued/a hold and restarted as ordered by the Doctor due to labs, these orders are handled as a discontinue hold of medication. There was no information obtained in review of records, other obtained documentation, and all conducted interviews that supported a violation occurred regarding the listed allegation. Based on the Department's investigation, interviews with staff and other parties, observations, and review of records, the allegation of "staff are mismanaging resident's medications" is 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 cited during today’s inspection.
Exit interview was conducted with Interim Administrator Karina Tapia.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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 2
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: 08/22/2024
NARRATIVE
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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 cited during today’s inspection.
Exit interview was conducted with Interim Administrator Karina Tapia.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina AlvisoTELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2