570300654-7-17-2020-21-AS-HDBI-BRZV7Q-20200730161128

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 570300654
Report Date: 07/17/2020
Date Signed: 07/17/2020 12:04:31 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
04/30/2020 and conducted by Evaluator Katrina Walters

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200430120212

FACILITY NAME:	ST. JOHN'S RETIREMENT VILLAGE/MANOR		FACILITY NUMBER:	570300654
ADMINISTRATOR:	THERESA J ELY		FACILITY TYPE:	740
ADDRESS:	135 WOODLAND AVENUE		TELEPHONE:	(530) 662-1290
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	174	CENSUS:	DATE:	07/17/2020
		UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Sean Belloud		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility failed to provide residents adequate meals
Staff do not meet residents’ needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Walters conducted a complaint investigation regarding the above captioned allegations. LPA Walters spoke with Executive Director Sean Belloud, this date, for the purpose of delivering findings by phone due to the COVID – 19 precautions. Interviews were conducted with residents, staff and various outside parties.

It was alleged facility staff are not meeting residents’ needs, more specifically, that residents are not receiving food in a timely manner and that meals are not adequate. Based on interviews and documents reviewed LPA learned that the facility was able to make necessary accommodations for all residents during the kitchen closure by having meals delivered from various restaurants.

Continued on 9099 C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020

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-20200430120212

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: ST. JOHN'S RETIREMENT VILLAGE/MANOR	FACILITY NUMBER: 570300654
	VISIT DATE: 07/17/2020

NARRATIVE

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LPA further learned through staff interviews that there were occasional delays in the restaurants delivering meals to the facility, but were delivered to residents when they arrived. Some residents have microwaves in their bedrooms. For those that don’t, servers are able to warm up resident meals. Interviews with residents confirmed that the meals were adequate and met their needs. On 04/27/2020 the kitchen was reopened and onsite preparation of meals resumed.

The Department has investigated the above allegations and have found that the complaint is UNFOUNDED, meaning that the allegations are false, could not have happened, and/or are without a reasonable basis. Therefore, the complaint is Dismissed.

No Deficiencies cited.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Katrina Walters	TELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020

LIC9099 (FAS) - (06/04)

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