496804113-9-10-2024-21-AS-CMAZ-DATPPB-20241108102914

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804113
Report Date: 09/10/2024
Date Signed: 09/10/2024 03:55:52 PM

Unsubstantiated

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
05/21/2024 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240521123549

FACILITY NAME:	FOUNTAINGROVE LODGE		FACILITY NUMBER:	496804113
ADMINISTRATOR:	LEONE, MEGAN E.		FACILITY TYPE:	741
ADDRESS:	4210 THOMAS LAKE HARRIS DRIVE		TELEPHONE:	(707) 576-1101
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	173	CENSUS:	DATE:	09/10/2024
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Megan Leone-Administrator		TIME COMPLETED:	04:10 PM

ALLEGATION(S):

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Staff do not prevent resident from entering another residents room
Staff do not prevent resident from causing harm to other residents
Staff are inappropriately locking resident rooms

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 9/10/24 at approximately 2:00pm, and met with Megan Leone, Administrator.

LPA reviewed resident (R1 & R2) records, facility records, and obtained copies of records. LPA conducted interviews with staff and other related parties. The investigation revealed that residents R1 and R2 reside in the memory care unit. Residents both have care plans in place, and per review, R1 & R2 are not one to one care need residents. Residents are able to walk around the memory care unit, as the residents are not to be restrained in any way. The memory care unit has a locked perimeter and residents may walk around freely if able to. Residents are monitored and will be redirected if needed. If a resident wanders into a room that is not theirs they are redirected by staff. Residents are able to have their rooms locked to ensure their privacy and to secure their belongings. Residents may have the key if they can manage having the key to their locked room;

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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-20240521123549

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: FOUNTAINGROVE LODGE	FACILITY NUMBER: 496804113
	VISIT DATE: 09/10/2024

NARRATIVE

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Residents may request entry into their room by staff at any time, if wanting to keep their room locked but can't manage having the key to their room. Staff will always assist a resident in having access to their room if they have it closed and locked. Residents may choose to have their rooms door closed and not locked, it is residents choice. Resident rooms may be locked and resident may have the key or not, this would be part of of a care plan with resident and/or responsible party. All resident rooms can be opened from the inside at all times, residents are never locked inside their rooms.

Per interviews, and review of records, R1 has a care plan in place and staff monitor as needed. If observed wandering into a resident room that is not theirs, the staff redirect the resident. R1 does get confused of where their room is, and sometimes does wander to the wrong area and/or side of rooms, confused when turned away and redirected. Residents are monitored and redirected by staff, but residents are not to be restrained, forced, pushed around, and/or grabbed roughly by any staff or any other individual working and/or visiting the facility/other resident; Per interviews with staff R1 has been a resident for less than a year, and there has been decline with R1, and staff have been working to meet residents needs. Per review of records/alert charts and interviews, staff were monitoring R1 and redirecting as needed. Residents are reassessed as needed, care plans updated when needed, the facility will do what they can before assessing the resident needs a higher level of care. Staff stated they address the needs of all residents in care. Staff denied to the LPA that they neglect residents in care and/or let residents harm themselves or other residents in care.

Per the investigation regarding the allegations that "staff do not prevent resident from entering another residents room, staff do not prevent resident from causing harm to other residents, staff are inappropriately locking resident rooms" there was no information obtained that supported violations had occurred regarding the allegations.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations are Unsubstantiated, meaning that 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.

No deficiencies cited.
Exit interview was conducted with the Administrator Megan Leone.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Dina Alviso	TELEPHONE: (707) 588-5082
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC9099 (FAS) - (06/04)

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