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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496890049
Report Date: 04/12/2021
Date Signed: 04/12/2021 03:14:54 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
02/19/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210219111301
FACILITY NAME:EXCEPTIONAL CARE HOMEFACILITY NUMBER:
496890049
ADMINISTRATOR:JONES, RICHARDFACILITY TYPE:
740
ADDRESS:393 BONNIE AVENUETELEPHONE:
(707) 205-1228
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 1DATE:
04/12/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Enrico MagalingTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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A resident was touched inappropriately
Facility staff not assisting a resident with nutrition needs
Staff not assisting a resident with incontinence needs
Facility is not safe guarding residents personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Enrico Magaling this date for the purpose of delivering findings on this complaint. The visit was conducted via Tele-Visit due to the Covid-19 precautions. LPA did not physically present at the site. This Department has investigated the above captioned allegations by interviewing staff, witnesses, and Complainant as well as obtaining and reviewing documents. Administrator has not responded to many phone and e-mail requests for interview and information. Based upon the records reviewed and interviews conducted the following determinations have been made: Deceased subject of the complaint, R1, reportedly told Complainant of having been touched inappropriately by staff while in the shower; There are no witnesses to the alleged act; R1 had a diagnosis of dementia. Complainant alleges that R1 did not receive essential nutritious food and was not kept clean by staff; Tele-Site visit by this Department found the facility well stocked with fresh and non perishable food; Responsible persons for current and previous residents indicate their loved ones were kept clean and well fed; Personnel from Hospice state that residents were observed to be consistently clean and well fed; R1 has documented history of refusing food and assistance with care. ****Continued on next page****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
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 6
Control Number 21-AS-20210219111301
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: EXCEPTIONAL CARE HOME
FACILITY NUMBER: 496890049
VISIT DATE: 04/12/2021
NARRATIVE
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It has been further alleged that a diamond ring belonging to R1 was missing on 11/12/2021. Staff indicate that the ring was found in the facility and put in safekeeping for R1 and that it was presented to the Responsible Person for R1 on 11/12/2021 as requested. Responsible person confirms the ring was returned on 11/12/2021. Although the allegations may have happened or are valid, based upon the interviews and records, there is not a preponderance of evidence to prove the violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/19/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210219111301

FACILITY NAME:EXCEPTIONAL CARE HOMEFACILITY NUMBER:
496890049
ADMINISTRATOR:JONES, RICHARDFACILITY TYPE:
740
ADDRESS:393 BONNIE AVENUETELEPHONE:
(707) 205-1228
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 1DATE:
04/12/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Enrico MagalingTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff did not give resident's medication as prescibed
Administrator has not paid responsible person refund due following resident's death
Facility grounds have bags of trash that have not been disposed of properly
Resident eloped through a window that had no device to alert staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert met with Enrico Magaling this date for the purpose of delivering findings on the above captioned complaint allegations. The visit was conducted via tele-visit due to the Covis-19 precautions. During the course of this investigation, the Department has interviewed staff and witnesses as well as obtained and reviewed documents. The following determinations have been made: Records show that R1 was not administered a medication(D..10mg 1xD) ordered by the physician between August 01 and August 05, 2020; C1 alleges that the facility owes a refund in the amount of $1770.00 following the death of R1; Administrator has not responded to repeated calls and e-mails requesting a statement for this Department regarding the allegation; Text messages between Administrator and
C1 support the allegation; During a facetime visit conducted on 02/22/2021 to the facility LPA observed numerous bags of trash piled along side the facility and was told by staff that the garbage service was cancelled for nonment; ****Continued on second page***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20210219111301
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: EXCEPTIONAL CARE HOME
FACILITY NUMBER: 496890049
VISIT DATE: 04/12/2021
NARRATIVE
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 Repeated requests for proof of the garbage removal have not been responded to; Complainant and staff state R1 eloped from the inside of the facility through an unalarmed window. Based upon the statements and photographs taken; text and documents reviewed, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20210219111301
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: EXCEPTIONAL CARE HOME
FACILITY NUMBER: 496890049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2021
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. Based upon statements and records reviewed, this requirement has not been met as evidenced by:

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Administrator to provide additional training to all staff on medication administration and shall provide a written plan that will ensure the timely administration of all medications ordered for residents. Proof of compliance to be provided to CCL by POC date in order to clear the deficiency.
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R1 was not administered a medication between 8/1 and 8/5/2020. This posed an immediate risk to the health of R1.

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Type A
04/15/2021
Section Cited
CCR
87303(a)
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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. *** Based upon statements, photographs, and face time site visit, this requirement has not been

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Administrator shall remove all trash from the facility grounds and show proof of instituting a regular garbage pick up by a recognized entity and shall provide proof of compliance to CCL in order to clear the deficiency.

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been met as evidenced by: LPA observed 12 to 18 bags of trash piled up along the side of the facility and was told by staff that the garbage service was discontinued for lack of payment. This posed an immediate risk to the health and safety of the residents.

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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20210219111301
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: EXCEPTIONAL CARE HOME
FACILITY NUMBER: 496890049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2021
Section Cited
CCR
87705(j)
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87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. ***Based upon statement taken, this requirement has not been met as evidenced by: Complainant reports and

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Administrator shall provide a written plan of how to ensure staff are alerted if a resident elopes through a window. Proof of compliance to be submitted to CCL by POC date in order to clear the deficiency.


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staff confirm that R1 eloped from inside the facility through a window that was not alarmed. This posed an immediate risk to the safety of R1.

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Type B
04/26/2021
Section Cited
HSC
1569.652(c)
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1569.652(c) H&S Code. A refund of any fees ... shall be issued to the individual, individuals, or entity contractually responsible for the fees or, .. to the resident’s estate, within 15 days after the personal property is removed. Based upon statements and text messages reviewed, this requirement has not been met as evidenced by: RP for R1 claims

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Administrator shall pay the refund due to R1 and provide proof of compliance to CCL by POC date.
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evidenced by: C1 states a refund of $1770.00 is due and not been paid; Administrator has not responded to numerous requests for statement regarding the allegation. This posed a potential violation of R1's personal Rights.

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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: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6