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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 570300654
Report Date: 12/23/2021
Date Signed: 03/01/2022 11:22:26 AM



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
08/31/2021 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20210831090555
FACILITY NAME:ST. JOHN'S RETIREMENT VILLAGE/MANORFACILITY NUMBER:
570300654
ADMINISTRATOR:WHEELER, HEIDI MARIEFACILITY TYPE:
740
ADDRESS:135 WOODLAND AVENUETELEPHONE:
(530) 662-1290
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:174CENSUS: 65DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Scott Sinclair, Assistant AdministratorTIME COMPLETED:
12:51 PM
ALLEGATION(S):
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9
Facility food service is not adequate and of poor quality.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nakagawa conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings on the above allegations and met with Scott Sinclair, Assistant Administrator. It is alleged the facility food service is not adequate and of poor quality. During the investigation LPA conducted interviews with staff, residents, reviewed records, and made observations at the facility on 3 separate occasions regarding the food service. On 08/31/2021 LPA toured the kitchen area with S1 where at least one week of non-perishable food and 2 day of perishable foods was observed. LPA did not observe any spoiled or expired food. Menu observed at the facility was current and overseen by the dieticians and regional supports of Morrison Healthcare.

Cont. on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
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 4
Control Number 21-AS-20210831090555
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: 12/23/2021
NARRATIVE
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Cont. from 9099

The following determinations have been made: There are differing opinions among the residents as to the quality of the food served; menus reviewed and food sampled comply with the regulatory guidelines enumerated in Title Twenty-Two; unannounced visits found the food to be tasty and well balanced; Dietary Department has R1 listed as Diabetic/No wheat or white bread-there is no reference to a soft diet. 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4
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
08/31/2021 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20210831090555

FACILITY NAME:ST. JOHN'S RETIREMENT VILLAGE/MANORFACILITY NUMBER:
570300654
ADMINISTRATOR:WHEELER, HEIDI MARIEFACILITY TYPE:
740
ADDRESS:135 WOODLAND AVENUETELEPHONE:
(530) 662-1290
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:174CENSUS: 65DATE:
12/23/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Scott Sinclair, Assistant AdministratorTIME COMPLETED:
12:51 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff does not follow safe food handling practices.
INVESTIGATION FINDINGS:
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LPA reviewed staff records, conducted interviews, toured the kitchen and dining areas and made observations of the facility. LPA observed on several visits that the kitchen was clean and well-stocked with fresh perishable foods and non-perishable foods. During 3 facility visits on 08/31/2021, 09/10/2021, and 11/19/2021 LPA observed kitchen staff wearing proper food safety apparel and safe food handling practices were maintained throughout meal preparation and service. Staff in the kitchen all have current Food Handlers Certification.

Cont. on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20210831090555
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: 12/23/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
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11
12
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Cont. from 9099-A

Dining room staff were observed wearing gloves and masks and following safe food handling with frequent hand washing. Food on the buffet was observed being covered between servings.

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.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill NakagawaTELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4