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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804053
Report Date: 12/02/2025
Date Signed: 12/02/2025 05:31:53 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
09/03/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250903164551
FACILITY NAME:NAZARETH ROSE GARDEN OF NAPAFACILITY NUMBER:
286804053
ADMINISTRATOR:RAGLAND, SHANTIFACILITY TYPE:
740
ADDRESS:903 SARATOGA DRIVETELEPHONE:
(707) 252-7488
CITY:NAPASTATE: CAZIP CODE:
94559
CAPACITY:44CENSUS: 31DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Shanti Ragland, AdministratorTIME COMPLETED:
05:45 PM
ALLEGATION(S):
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Staff did not address a resident’s scabies infection in a timely manner.
INVESTIGATION FINDINGS:
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On 12/02/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint #21-AS-20250903164551 investigation findings regarding the above allegation and met with Shanti Ragland, Administrator. Reporting Party (RP) alleges that staff did not address a resident’s scabies infection in a timely manner.

LPA Florio conducted 10-day complaint investigation visit on 09/04/2025 and obtained documents and made observations. Per physician's reports dated 09/22/2022 and 11/19/2024, no skin conditions were mentioned for Resident 1 (R1).

On 10/28/2025, LPA returned to facility to conduct interviews, obtain additional documents, and make observations.

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

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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-20250903164551
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: NAZARETH ROSE GARDEN OF NAPA
FACILITY NUMBER: 286804053
VISIT DATE: 12/02/2025
NARRATIVE
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Continued from LIC9099...

Per documents obtained during this visit, Hospice orders for R1 revealed medications specifically prescribed for scabies dating back to 12/2023. Additionally, obtained Hospice progress notes dated from 06/17/2024 through 07/17/2025 do not mention scabies specifically -- only observed rashes and itching and recommendations for addressing the symptoms, such as continuing with washing affected areas and applying ointments and giving medications as prescribed. Centrally stored medication destruction records and medication administration records for R1 during the months of July and August 2025, revealed that the medications were given as ordered when the facility was able to get them refilled. Per an interview with Staff 1 (S1), R1 graduated off Hospice around July 15, 2025 which was providing R1 with two (2) additional baths per week and physician oversight to order and refill prescriptions. Per S1, facility staff observed R1's rash worsening around the beginning of August and notified the family and R1's prior primary care physician (PCP). The PCP notified the facility they were retiring and that R1 would need to find a new PCP. However, PCP referred R1 for home health services in the interim. Per S1, the facility's recommended physician would not accept R1, so the family found their own PCP, who per a Healthcare Provider Communication form dated and signed 08/09/2025, evaluated R1 and indicated suspected scabies which were later confirmed by a dermatologist on 08/14/2025. Per interview conducted with S1 and medication administration records for 08/2025, the facility immediately followed the doctors orders in regards to cleaning, bathing, care, treatment, and isolation. S1 states that the rash has cleared and R1 is doing better.

Today, 12/02/2025, LPA interviewed complainant who indicated that R1's skin has improved and has cleared up. LPA was unable to find any evidence to support that the facility staff did not address a resident’s scabies infection in a timely manner. Based on observations made, interviews conducted, and records reviewed, the Department received conflicting information regarding the above allegations.

Based on interviews conducted, observations made, and records obtained, the allegations that staff did not address a resident’s scabies infection in a timely manner 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 Administrator, whose signature on form confirms receipt of document(s).
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2