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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 577005609
Report Date: 06/06/2023
Date Signed: 06/08/2023 09:06:34 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/19/2023 and conducted by Evaluator Jill Nakagawa
COMPLAINT CONTROL NUMBER: 21-AS-20230519084050
FACILITY NAME:PALM GARDENSFACILITY NUMBER:
577005609
ADMINISTRATOR:LAUREN ANDERSENFACILITY TYPE:
740
ADDRESS:240 PALM AVETELEPHONE:
(530) 661-0574
CITY:WOODLANDSTATE: CAZIP CODE:
95695
CAPACITY:100CENSUS: 63DATE:
06/06/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Lauren Andersen, AdministratorTIME COMPLETED:
03:47 PM
ALLEGATION(S):
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Staff are not providing access to a resident's records
INVESTIGATION FINDINGS:
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Licensing Program Analyst Jill Nakagawa arrived unannounced to complete investigation and deliver findings regarding the above allegation and met with Lauren Andersen, Administrator.

LPA conducted interviews with the reporting party and several staff members and found that requested documentation had been requested by the reporting party and not received in a timely manner.

(Continued on 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
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 3
Control Number 21-AS-20230519084050
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PALM GARDENS
FACILITY NUMBER: 577005609
VISIT DATE: 06/06/2023
NARRATIVE
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(Continued from 9099)

Staff S1 had sent the request to S2 who reported that they had compiled the documentation and forwarded it to S3 to review and forward to the reporting party. S3 failed to communicate with either staff or the reporting party regarding the request nor did S3 forward any documentation as requested in a timely manner (within 2 business days). Based on LPA’s observations and interviews, the preponderance of evidence has been met, therefore the allegation that Staff are not providing access to a resident’s records is substantiated. California Code of Regulations, (Health and Safety Code 1569.269 (a)(21) are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20230519084050
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PALM GARDENS
FACILITY NUMBER: 577005609
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2023
Section Cited
HSC
1569.269
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1569.269 Enumerated rights:(a) residents of RCFE's shall have following:(21)To have prompt accesss...not to exceed two businesss
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Licensee will forward receipt of enumerated rights to CCL within one business day and include a statement of how enumerated rights will be
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days at a cost not to exceed the community standard for photocopies. Licensee failed to provide requested records in a timely manner.
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taken care of at the facility going forward & Licensee will assign responsibility for fulfilling req. for documentation and inform Dept. w/in 24 hours.
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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: Kimberley Mota
LICENSING EVALUATOR NAME: Jill Nakagawa
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3