496803929-5-20-2022-21-AS-BMOS-CEQTV5-20220524150320

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803929
Report Date: 05/20/2022
Date Signed: 05/20/2022 12:55:25 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
05/09/2022 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220509083756

FACILITY NAME:	MAGGIE'S CARE HOME		FACILITY NUMBER:	496803929
ADMINISTRATOR:	GARCIA, MAGGIE		FACILITY TYPE:	740
ADDRESS:	916 RENEE COURT		TELEPHONE:	(707) 293-9833
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY:	6	CENSUS: 6	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Maggie Garcia (Licensee)		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident eloped from the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Licensee, Maggie Garcia to deliver findings regarding the complaint allegations above.

It was alleged that resident (R1) eloped from the facility. Reporting Party stated that on 5/9/2022, R1 was found by a "good Samaritan" wandering in downtown Santa Rosa. The good Samaritan took R1 to Santa Rosa Memorial Hospital for evaluation. Per Reporting Party, hospital staff called the facility three times however, no one answered the facility phone. During the course of this investigation, LPA reviewed R1’s physician report dated 2/8/21 indicating that R1 has a diagnosis of Dementia including wandering behaviors and was not able to leave facility unassisted. However, R1’s needs and services plan dated 1/21/22 does not address those behaviors. On 5/10/22 LPA conducted 10-day complaint investigation where LPA inspected the area used by the resident to leave the facility including auditory device located at the front door of the facility and it was working properly. Also, LPA observed the resident in care and noticed that bathroom used by staff did not have installed a ventilation fan that will affect that S1 wouldn't hear the sound of the alarm.
Continues on LIC809C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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 3

Control Number 21-AS-20220509083756

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: MAGGIE'S CARE HOME	FACILITY NUMBER: 496803929
	VISIT DATE: 05/20/2022

NARRATIVE

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Continued from LIC9099...

Per incident report submitted to CCL on 5/11/22. “The morning of 5/8/22 approximately around 3am, R1 hit all the sensor alarms then when they noticed that the caregiver went to use the bathroom, R1 left the facility. Around 5am caregiver noticed that R1 was not in their bedroom, a “policeman” came and told S1 that R1 was found and at the hospital. Licensee was contacted by S1, R1 was picked up from Hospital and responsible parties were notified”. During confidential interviews conducted with facility staff, LPA obtained contradictory information about the incident and it was revealed that S1 who was working the night of the incident did not have a criminal record clearance, they were not associated to the facility and did not have required staff training to be providing care and supervision to residents in care. LPA already addressed criminal record clearance deficiency on a case management conducted on 5/10/22 and civil penalties were issued. On 5/18/2022 LPA obtained a copy of service calls confirming that R1 had wandered away from the facility on 5/9/22 and not on 5/8/22 as reported on incident report submitted to CCL. However, Facility did not follow their AWOL policy and procedures about notify CCL by telephone no later than next working day and it will be address in a case management. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20220509083756

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: MAGGIE'S CARE HOME	FACILITY NUMBER: 496803929
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/21/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Type A: 87411(a) Personnel Requirements-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee to ensure that R1’s care plan is updated including wandering behaviors and all staff are trained in dementia care-specifically elopement procedures and policy including response to auditory alarms. Licensee agreed to provide scheduled dates for all staff trainings to CCL by POC due date.
	8 9 10 11 12 13 14	Based on records review, observations and interviews conducted with facility staff, Licensee did not ensure that staff (S1) was competent to provide services resulting in R1 wandered away from facility on 5/8/22 which poses an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14
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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: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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