496803905-1-11-2023-21-AS-CMAZ-CN82JR-20230118162646

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803905
Report Date: 09/09/2022
Date Signed: 01/11/2023 07:37:29 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
07/07/2022 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220707103221

FACILITY NAME:	ARBOL RESIDENCES OF SANTA ROSA		FACILITY NUMBER:	496803905
ADMINISTRATOR:	SORIANO, MARIELE		FACILITY TYPE:	741
ADDRESS:	300 FOUNTAINGROVE PARKWAY		TELEPHONE:	(707) 566-8600
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	152	CENSUS: 82	DATE:	09/09/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Brooke Robichaud,-Administrator		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Facility does not meet food service requirements

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso arrived unannounced to conduct a complaint investigation, on 9/9/2022 at approximately 1:00pm, regarding the above allegation. LPA met with Assistant RCFE Administrator, Brooke Robichaud, who is the skilled nursing building's Administrator of this Continuing Care Retirement Community (CCRC).

This is a subsequent inspection being conducted. LPA reviewed facility records, and conducted interviews with staff, and other related parties, regarding the allegation. LPA toured the kitchen regarding food storage and service.
Per LPA's review and observations of the facility's food service, interviews with staff, and interviews with other related parties, the investigation revealed that food supply was sufficient, all food perishable and unperishable, were stored appropriately, labeled and dated.

continued on LIC9099C...

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: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

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-20220707103221

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: ARBOL RESIDENCES OF SANTA ROSA	FACILITY NUMBER: 496803905
	VISIT DATE: 09/09/2022

NARRATIVE

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LPA did not observe any food that was rotting, didn't look fresh and/or unsafe to consume. LPA observed the food menus, breakfast, lunch, and diner menu, including the anytime menu, and the snack menu. All facility residents have the same menus to choose from, including the snack menu. There was different information obtained from parties interviewed regarding the allegation.

Based on the Department's investigation, interviews, observations, and review of records, the allegation of "facility does not meet food service requirements" 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/citations during today’s visit.
Exit interview was conducted with the Brooke Robichaud, RCFE back-up Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022

LIC9099 (FAS) - (06/04)

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