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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286802019
Report Date: 05/26/2022
Date Signed: 05/26/2022 11:24:58 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
02/15/2022 and conducted by Evaluator Erik Gonzalez Campos
COMPLAINT CONTROL NUMBER: 21-AS-20220215144846
FACILITY NAME:LINDA FALLS GUEST HOME 1FACILITY NUMBER:
286802019
ADMINISTRATOR:SACRO, NORBERTFACILITY TYPE:
740
ADDRESS:755 LINDA FALLS TERRACETELEPHONE:
(707) 963-1440
CITY:ANGWINSTATE: CAZIP CODE:
94508
CAPACITY:6CENSUS: 6DATE:
05/26/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Norbert SacroTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility retained a resident with a prohibited condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Gonzalez Campos conducted an investigation regarding the allegation above. LPA arrived unannounced on 05/26/2022 to deliver complaint findings.

On 02/15/2022 Community Care Licensing recieved a report that resident was admitted to the hospital from the facility with a pressure injury. LPA conducted interviews with hospital staff who indicated injury was documented at admission and photographs were taken. LPA requested Investigations Branch (IB) request documentation from hospital. Review of hospital records revealed that resident was admitted with an unstageable wound, a prohibited health condition. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation has been SUBSTANTIATED.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
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 2
Control Number 21-AS-20220215144846
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: LINDA FALLS GUEST HOME 1
FACILITY NUMBER: 286802019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2022
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:
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Licensee is now aware unstagable pressure injuries are considered a prohibited condition. Licensee agrees to submit a written policy on steps to be taken by the facility should one of the residents require services for a prohibited health condition in order for the Licensee to remain in compliance with regulation.
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Based on record review, resident was admitted to the hospital with an unstagable wound. Facility retatined a resident with a prohibited health condition without notifying CCL which posed a potential health and safety risk to resident in care.
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 Licensee to submit the policy to CCL by POC date of 06/03/2022.
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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: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2