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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803960
Report Date: 01/23/2025
Date Signed: 01/23/2025 03:12:17 PM

Substantiated


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
10/25/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241025102653
FACILITY NAME:ELSA'S HOMEFACILITY NUMBER:
496803960
ADMINISTRATOR:WAINAINA, KENNEDYFACILITY TYPE:
740
ADDRESS:10 CREEKVIEW COURTTELEPHONE:
(707) 539-5625
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Co-Administrator Alfonso GalvezTIME COMPLETED:
03:26 PM
ALLEGATION(S):
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Staff did not ensure medication was inaccessible to resident in care
Staff mismanaged residents' medication
Staff did not follow physician orders
Staff did not ensure carpet was clean resulting in resident's feet getting dirty
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christi Coppo and Ali Deniz arrived unannounced to deliver findings on the above complaint allegations and met with co-Administrator, Alfonso Glavez.

Complaint alleges that staff did not ensure medication was inaccessible to resident. During investigation, on the morning of 11/1/24, LPA observed one medication tablet in pre-poured cup, being reserved for an afternoon administration. Per caregiver, the medication was to be administered later that afternoon. LPA observed medication tablet to be left out in the open and readily accessible to all that were present in the facility. Based on LPA observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

Complaint alleges that staff mismanaged residents' medication and staff did not follow physician’s orders. During investigation, LPA reviewed physician’s

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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 7
Control Number 21-AS-20241025102653
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: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 01/23/2025
NARRATIVE
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Continued from 9099...

orders, facility’s medication list, and the Centrally Stored Medication Log (CSML) for resident (R1). Two [2] discrepancies were found. A discrepancy was found in regard to the medication Gabapentin. The doctor’s orders show R1 was to receive two [2] tabs of 100mg gabapentin three times per day. However, both on the facility’s medication list and the CSML, the dose of gabapentin required was listed as only one [1] 100mg tablet three [3] times per day. During investigation, LPA interviewed staff that reported the medication dose had been lowered from two tabs to one tab on 10/22/24. However, the hospital discharge papers were dated 10/11/24 and they included the prescription documentation for the gabapentin. Per LPA review, the dose R1 was to receive was listed as two [2} tabs three [3] times per day, and therefore no change had been made to the accounts of the total number of gabapentin tablets R1 was to receive.

Additionally, on 10/11/24, R1 was prescribed 20 mg of prednisone, three [3] tablets to be taken every morning for a total of 5 days. During investigation, staff advised LPA that since the medication was only prescribed for 5 days, that it wasn’t added to the CSML but was added to the Medication Administration Record (MAR) instead. However, LPA observed the prednisone prescription added to the CSML. LPA also observed the MAR to indicate that the prednisone was administered to R1 on 11/11/24-11/15/24. However, the resident did not return from the hospital until after 5:00pm on 11/11/24 and per the physician’s order’s the prednisone was to begin being administered by the facility on the morning of 11/12/24. During investigation, LPA received evidence that R1’s prednisone prescription filled on 11/11/24 had 8 out of 15 pills remaining. Based on LPA observation and evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

Complaint alleges staff did not ensure carpet was clean resulting in resident's feet getting dirty. During investigation, LPA received police report. Witness (I2) reported that they observed the carpet in R1’s room to be dirty, R1’s bathroom floor to be sticky, and noticed R1’s feet to be dirty. I2 indicated that R1’s feet were dirty due to walking on the sticky bathroom floor then subsequently walking on the dirty carpet. Additionally, witness (I3) reports observing R1’s carpet to be heavily soiled and R1’s feet to be blackened with dirt. Based on evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

Continued on 9099C(2)

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 21-AS-20241025102653
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: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 01/23/2025
NARRATIVE
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Continued from 9099C...

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Co-administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Co-administrator and a copy of this report was given.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
10/25/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241025102653

FACILITY NAME:ELSA'S HOMEFACILITY NUMBER:
496803960
ADMINISTRATOR:WAINAINA, KENNEDYFACILITY TYPE:
740
ADDRESS:10 CREEKVIEW COURTTELEPHONE:
(707) 539-5625
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: DATE:
01/23/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Co-Administrator Alfonso GalvezTIME COMPLETED:
03:26 PM
ALLEGATION(S):
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Staff did not seek timely medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christi Coppo aand Ali Deniz arrived unannounced to deliver findings on the above complaint allegation and met with co-Administrator, Alfonso Glavez.

Complaint alleges that staff did not seek timely medical care for resident. Complaint alleges that the emergency room doctor said R1 should have been brought in hours ago or last night for their breathing issue as they were in acute hypoxic respiratory failure. Additionally, R1 has a history of breathing trouble as they have COPD. During investigation, LPA received conflicting accounts of the severity of R1’s struggling to breathe during the incident. During investigation, LPA reviewed emergency room doctor and social worker notes. Upon admission, R1 was diagnosed with 3 diagnoses: #1- Acute Exacerbation of COPD, #2 hypoxia, and #3 lactic acidosis. However, emergency room notes indicate “not technically hypoxic on arrival” and R1 was assigned a severity level of service of visit level 5, which

Continued on 9099A(c)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
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 7
Control Number 21-AS-20241025102653
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: ELSA'S HOME
FACILITY NUMBER: 496803960
VISIT DATE: 01/23/2025
NARRATIVE
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Continued from 9099A...

indicates a “non-urgent” priority level. LPA not able to confirm definition of level of service codes with Kaiser after repeated attempts. LPA not able to corroborate allegation by either the Emergency room (ER) doctor’s notes or the ER Social Worker’s notes. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 21-AS-20241025102653
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: ELSA'S HOME
FACILITY NUMBER: 496803960
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/24/2025
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored
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Facility to submit to CCL LIC9098 self-certifying that all staff will immediately cease pre-pouring medications and will ensure all medications are locked in medication closet at all times. LIC9098 to be submitted to CCL by plan of correction due date.
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 medication. Based on LPA observation, the licensee did not comply with the section cited above in that LPA observed one medication tablet in pre-poured cup, being reserved for an afternoon administration, which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
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Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist
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Facility Admin agrees to submit LIC9098 self-certfying they will complete medical training. Training to be completed and training certificates submitted for Medication Training in the amount of 8 hours by no later than 2/13/25. Admin agrees to complete the training from the approved vendor Relias.
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residents with self-administered medications as needed. Based on LPA investigation and record review, the licensee did not comply with the section cited above in that LPA reviewed physician’s orders, facility’s medication list, and the Centrally Stored Medication Log (CSML) for resident (R1) two [2] discrepancies were found pertaining to the doctor’s orders and prescriptions for gabapentin and prednisone, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 21-AS-20241025102653
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: ELSA'S HOME
FACILITY NUMBER: 496803960
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/13/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: 2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Admin to complete one course on Personal Rights training by plan of correction due date of 2/13/25. Admin agrees to complete the training from the approved vendor Relias.
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Based on LPA investigation and record review, the licensee did not comply with the section cited above in that staff did not ensure carpet was clean resulting in resident's feet getting dirty, which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7