496803924-6-2-2021-21-AS-KMOA-C4XPHZ-20210715112046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803924
Report Date: 06/02/2021
Date Signed: 06/02/2021 04:50:26 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
02/10/2021 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210210080251

FACILITY NAME:	SONOMAMODELX		FACILITY NUMBER:	496803924
ADMINISTRATOR:	FLORES, MARIA		FACILITY TYPE:	740
ADDRESS:	765 DONALD STREET		TELEPHONE:	(415) 264-5486
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	32	CENSUS: 15	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Maria "Ines" Flores		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not allow resident access to personal possessions.
Staff mismanaged resident's medications and records.
Staff did not follow resident's doctors orders.
Residents were hit by a dementia resident.
Staff member pushed dementia resident.
Staff did not seek resident timely medical attention.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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At approximately 12:00PM, Licensing Program Analyst's (LPA's) Shannan Hansen and Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA's met with Administrator Maria "Ines" Flores, toured the facility, interviewed staff and reviewed records. Based on interviews conducted, resident had access to personal belongings that were allowed in the facility. Staff did remove access to an item due to a safety concern. LPA Arnhold reviewed Medication records and found them to be in order. Physician orders were in place and followed by facility. Based on Interviews conducted about resident violence, LPA learned staff are not always able to prevent residents from hitting other residents. Staff do intervene and separate residents, when needed, to ensure the safety of all residents. There was no evidence to support the claim that a staff member pushed a resident. Based on interviews conducted, the only incident that could be recalled was when a staff member redirected a resident who was attempting to hit another resident and resident focused on staff. The resident attempted to hit staff and lost balance, and staff assisted the resident to the ground. Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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 4

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
02/10/2021 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210210080251

FACILITY NAME:	SONOMAMODELX		FACILITY NUMBER:	496803924
ADMINISTRATOR:	FLORES, MARIA		FACILITY TYPE:	740
ADDRESS:	765 DONALD STREET		TELEPHONE:	(415) 264-5486
CITY:	SONOMA	STATE: CA	ZIP CODE:	95476
CAPACITY:	32	CENSUS: 15	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Maria "Ines" Flores		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff lack training and qualifications.

INVESTIGATION FINDINGS:

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At approximately 12:00PM, Licensing Program Analyst's (LPA's) Shannan Hansen and Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA's met with Administrator Maria "Ines" Flores and reviewed records. Based on a review of staff training records, documentation was not present to show the required number of hours needed to meet regulation. Ines told LPA's they conduct training monthly and will ensure proper documentation is completed in the future.
Based on LPA’s observations, interviews conducted and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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 4

Control Number 21-AS-20210210080251

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: SONOMAMODELX	FACILITY NUMBER: 496803924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2021 Section Cited CCR 87412(c)	1 2 3 4 5 6 7	87412 Personnel Records. (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Licensee did	1 2 3 4 5 6 7	Licensee agrees to document training as required. Licensee to submit plan to CCL that outlines how they will document required training. Plan to be submitted by POC date of 06/30/2021
	8 9 10 11 12 13 14	not ensure required verification of training was in each staff file. This poses a potential Safety risk to 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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20210210080251

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: SONOMAMODELX	FACILITY NUMBER: 496803924
	VISIT DATE: 06/02/2021

NARRATIVE

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Based on interviews conducted, staff contacted medical personnel when needed. Staff observed residents for changes in condition and respond accordingly.
Based on physical tour of the facility and LPA observations, the facility is in good repair. Walkways were free from obstruction and doorways were clear.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

No citations issued.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC9099 (FAS) - (06/04)

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