496803924-6-2-2023-21-AS-CMAZ-CSN2QY-20230609173644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803924
Report Date: 06/02/2023
Date Signed: 06/02/2023 01:44:56 PM

Substantiated

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
04/26/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230426161815

FACILITY NAME:	SONOMAMODELX		FACILITY NUMBER:	496803924
ADMINISTRATOR:	ALEXANDER VARSHAVSKY		FACILITY TYPE:	740
ADDRESS:	765 DONALD STREET		TELEPHONE:	(415) 264-5486
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	32	CENSUS: 23	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Med Tech/Receptionist, Juliana Sanchez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff are mishandling resident's medication log.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at SonomamodelX for the purpose of delivering complaint findings. LPA was greeted at the door by Med Tech/Receptionist, Juliana Sanchez, and was granted access into the facility.

During the course of the investigation, LPA Sarangi reviewed facility records including the Medication Assessment Record (MAR).

Complaint alleges that Staff are mishandling resident's medication log. During the opening of the complaint on April 27, 2023, LPA reviewed the Medication Assessment Record (MAR) with the Administrator for the month of April 2023 and learned that tracking of the medication was not being documented as outlined in the facilities Program Plan of Operation. LPA reviewed the Program Plan of Operation/Program Philosophy on May 18, 2023.

(Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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 5

Control Number 21-AS-20230426161815

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: SONOMAMODELX	FACILITY NUMBER: 496803924
	VISIT DATE: 06/02/2023

NARRATIVE

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and observed on page 4 & 5 of the Program Plan of Operation/Program Philosophy it indicates the following, "All medication assistance will be documented with the medication name, time, date and dosage taken by the resident, or documentation that the resident did not take the medication according to the prescription. All documentation will be accompanied by a signature of the trained staff member that has passed the medication. This will include any type of medication pass." (See LIC 809D and Document Review-Program Plan of Operation/Program Philosophy)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed by the Med Tech/Receptionist, Juliana Sanchez and emailed to the Administrator due to printer issues.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 21-AS-20230426161815

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: SONOMAMODELX	FACILITY NUMBER: 496803924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/09/2023 Section Cited CCR 87208(a)	1 2 3 4 5 6 7	87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval.	1 2 3 4 5 6 7	Licensee shall submit a LIC 9098 understanding the regulation. In addition, Licensee shall send the most updated Program Plan of Operation.
	8 9 10 11 12 13 14	This requirement was not met at evidenced by: Based on observation of the Medication Assessment Record (MAR) during the opening of the complaint on April 27, 2023, LPA observed that the Program Plan of Operation was not being followed as it relates to Medication Policies and Procedures. Furthermore, during a review of the MAR on April 27, 2023, LPA and Administrator observed two residents that did not have the MAR properly documented and had the month of April 2023 missing from the MAR.	8 9 10 11 12 13 14	POC due date is June 9, 2023.
	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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/26/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230426161815

FACILITY NAME:	SONOMAMODELX		FACILITY NUMBER:	496803924
ADMINISTRATOR:	ALEXANDER VARSHAVSKY		FACILITY TYPE:	740
ADDRESS:	765 DONALD STREET		TELEPHONE:	(415) 264-5486
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	32	CENSUS: 23	DATE:	06/02/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Med Tech/Receptionist, Juliana Sanchez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained a pressure injury while in care.
Staff has not address scabies outbreak in facility.
Staff are not meeting resident care needs
Staff does not ensure resident's room is sanitary and clean.
Staff does not ensure resident's medications are properly stored.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at SonomamodelX for the purpose of delivering complaint findings. LPA was greeted at the door by Med Tech/Receptionist, Juliana Sanchez, and was granted access into the facility.

During the course of the investigation, LPA Sarangi reviewed resident records, facility records, interviewed staff, residents and various outside parties, including but not limited to witnesses.

Complaint alleges that resident sustained a pressure injury while in care. Based on the interviews that were conducted, LPA learned that the resident presented to the facility with a pressure injury that was getting addressed by the Hospice Agency. LPA attempted to get a hold of the Hospice Nurse for interviewing purposes, but was unsuccessful in that attempt. Furthermore, LPA could not prove or disprove the allegation due to inconsistent statements made throughout the course of the investigation. (Report continued on LIC 9099C).

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20230426161815

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: SONOMAMODELX	FACILITY NUMBER: 496803924
	VISIT DATE: 06/02/2023

NARRATIVE

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Complaint alleges that Staff has not address scabies outbreak in facility. Based on the interviews that were conducted with the facility and an outside agency, LPA learned that the facility reported the Scabies outbreak via facsimile to the appropriate Public Health Entity. Furthermore, LPA received proof that the facility reported to their respective Public Health Entity. An incident report was forwarded to Santa Rosa Regional Office on April 3, 2023 indicating that the facility had an outbreak of scabies and that the facility was following their Infection Control Plan.

Complaint alleges that Staff are not meeting resident care needs. Based on interviews that were conducted with residents in care and a witness, LPA could not prove or disprove the allegation due to inconsistent statements made during the course of the investigation.

Complaint alleges that Staff does not ensure resident's room is sanitary and clean. During the opening of the complaint on April 27, 2023 and during a subsequent complaint investigation inspection conducted on May 16, 2023, LPA toured the facility on both dates and observed the facility to be appropriately cleaned and at a comfortable temperature with all exits free from obstruction. LPA observed the facility to be smelling appropriate and observed ALL resident bathrooms. Resident bathrooms observed to be appropriate during the inspection. Resident rooms observed to be appropriate and smelling good during the course of the investigation.

Complaint alleges that staff does not ensure resident's medications are properly stored. During the opening of the complaint on April 27, 2023, LPA observed the medication cart was locked and secured. During a subsequent complaint investigation inspection conducted on May 16, 2023, LPA observed medication cart being locked and secured at the time of the subsequent complaint investigation inspection

A finding that the complaint allegations of Resident sustained a pressure injury while in care. Staff has not address scabies outbreak in facility. Staff are not meeting resident care needs Staff does not ensure resident's room is sanitary and clean. Staff does not ensure resident's medications are properly stored 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, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed by the Med Tech/Receptionist, Juliana Sanchez, and emailed to the Administrator due to printer issues.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC9099 (FAS) - (06/04)

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