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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804030
Report Date: 12/09/2025
Date Signed: 12/09/2025 12:40:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
07/01/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250701084339
FACILITY NAME:BERKSHIRE, THEFACILITY NUMBER:
286804030
ADMINISTRATOR:DHAWAN, BABITAFACILITY TYPE:
740
ADDRESS:2300 BROWN STREETTELEPHONE:
(510) 996-8520
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:72CENSUS: 21DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lia Miller, Director of OperationsTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff neglect resulted in resident sustaining a fracture
INVESTIGATION FINDINGS:
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On 12/09/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250701084339 investigation findings and met with Lia Miller, Director of Operations. Reporting Party (RP) alleges that staff neglect resulted in resident sustaining a fracture.

LPA Florio conducted 10-day complaint investigation visit on 07/01/2025 and obtained documents, made observations, and conducted interviews. On 6/25/2025, at about 1927 hours, Resident 1 (R1) was admitted to a local emergency department (ED) with complaints of a swollen leg and was diagnosed with a right femur fracture and a hip fracture. On 6/26/2025, R1 had surgery for a hip fracture where a cephalomedullary nail was inserted. R1 was diagnosed with a comminuted proximal femur fracture with a non displaced neck component. Several staff interviews revealed consistent statements of not knowing how R1 had sustained an injury given that R1 was bed bound and unable to get out of bed on their own.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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-20250701084339
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BERKSHIRE, THE
FACILITY NUMBER: 286804030
VISIT DATE: 12/09/2025
NARRATIVE
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Continued from LIC9099...

Staff 1 (S1) learned that R1 had a controlled fall on 6/24/2025 when Staff 2 (S2) and Staff 3 (S3) were waking R1 up. S1 assumed that staff had R1 slide from the bed to the floor. R1 did not have any indications of pain at this time. R1 would not be able to say if they were in pain. Staff 4 (S4) stated that S2 was responsible for waking R1 up and changing their incontinent briefs. S2 told S4 that they dropped R1 while changing their briefs. S3 was unaware of R1 falling but stated that it was possible for S2 to have changed R1 alone resulting in R1 falling. S2 denied knowing anything about R1 being dropped or sliding to the floor. All of the staff knew that R1 was to be changed or moved with two staff present for a two person transfer. Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding the above allegation.

Based on interviews conducted, observations made, and records obtained, the allegation staff neglect resulted in resident sustaining a fracture is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted with Director of Operations, whose signature on form confirms receipt of document(s).
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2