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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801218
Report Date: 06/11/2025
Date Signed: 06/11/2025 12:10:37 PM

Substantiated


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
03/14/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250314120850
FACILITY NAME:DOVER VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801218
ADMINISTRATOR:CECILIA JUANILLOFACILITY TYPE:
740
ADDRESS:752 ROSEMARY COURTTELEPHONE:
(707) 427-1105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
06/11/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Edward Gadia, House ManagerTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Neglect, lack of supervision, facility did not seek timely medical
INVESTIGATION FINDINGS:
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On 06/11/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250314120850 investigation findings regarding the above allegation and met with Edward Gadia, House Manager. Reporting Party (RP) alleges that the facility did not seek timely medical for Resident 1 (R1).

LPA Florio conducted 10-day complaint investigation visit on 03/19/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through an interview with the House Manager (HM) that there was a pressure injury present “probably a stage 1-2” that had not yet been evaluated and staged by R1’s primary care physician (PCP).

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

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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 5
Control Number 21-AS-20250314120850
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: DOVER VALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 486801218
VISIT DATE: 06/11/2025
NARRATIVE
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Continued from LIC9099...

Per progress noted dated 03/14/2025, HM was verbally notified by R1’s PCP to begin monitoring, turning, and repositioning R1, at which time HM observed the pressure injury. Further interviews with R1 and Staff 1 (S1), revealed that the facility was aware of R1's discomfort and the injury that was forming for at least a week prior to R1’s wound being evaluated and staged by their PCP and that visit was initiated by R1’s family on March 19, 2025. On March 24, 2025, LPA received a copy of R1’s Doctor’s Orders indicating the pressure injury was a “stage 2” pressure injury. Based on interviews conducted and records reviewed, the facility was unable to provide proof of a medical assessment being sought for R1 in the time prior to the staging which resulted from the family’s efforts, (see LIC9099D). An immediate civil penalty in the amount of $500 if being issued during today's visit, (see LIC421IM). R1 was sent to the hospital for generalized weakness on 03/20/2025. At that time R1's family notified facility that R1 would not be returning.

Based on interviews conducted and records obtained, the allegation that the facility did not seek timely medical for R1 is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). The House Manager was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

Exit interview conducted. Copy of report discussed and provided to House Manager, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250314120850
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: DOVER VALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 486801218
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2025
Section Cited
CCR
87465(a)(2)
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Incidental Medical and Dental Care 87465(a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs….
This requirement is not met as evidenced by:
Based on facility not ensuring R1 was sent
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Licensee to submit self-certification that regulations 87465 Incidental Medical and Dental Care and 87466 Observation of a Resident have been reviewed with facility staff and are understood to CCL by POC due date 06/12/2025.
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out for timely medical evaluation of observed changes to R1's condition, resulting R1's family seeking medical attention and diagnosis of a stage 2 pressure injury, which posed an immediate health, safety, and personal rights risk to persons in care.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/14/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250314120850

FACILITY NAME:DOVER VALLEY RESIDENTIAL CARE HOMEFACILITY NUMBER:
486801218
ADMINISTRATOR:CECILIA JUANILLOFACILITY TYPE:
740
ADDRESS:752 ROSEMARY COURTTELEPHONE:
(707) 427-1105
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
06/11/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Edward Gadia, House ManagerTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
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9
Facility failed to observe change of condition
INVESTIGATION FINDINGS:
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On 06/11/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250314120850 investigation findings regarding the above allegations and met with Edward Gadia, House Manager. Reporting Party (RP) alleges that the facility failed to observe change of condition for Resident 1 (R1).

LPA Florio conducted 10-day complaint investigation visit on 03/19/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through an interview with the House Manager (HM) that there was a pressure injury present “probably a stage 1-2” that had not yet been evaluated and staged by R1’s primary care physician (PCP). Per progress notes dated 03/14/2025, HM was verbally notified by R1’s PCP to begin monitoring, turning, and repositioning R1, at which time HM observed the pressure injury.

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

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250314120850
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: DOVER VALLEY RESIDENTIAL CARE HOME
FACILITY NUMBER: 486801218
VISIT DATE: 06/11/2025
NARRATIVE
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Continued from LIC9099A...


Further interviews with R1 and Staff 1 (S1), revealed that the facility was aware of R1's discomfort and the injury that was forming for at least a week prior to R1’s wound being evaluated and staged by their PCP and that visit was initiated by R1’s family on March 19, 2025. On March 24, 2025, LPA received a copy of R1’s Doctor’s Orders indicating the pressure injury was a “stage 2” pressure injury. Based on interviews and record review, the facility was unable to provide proof of a medical assessment being sought for R1 in the time prior to the staging which resulted from the family’s efforts. On 03/20/2025 R1 was sent to the hospital for generalized weakness. At that time R1's family notified the facility that R1 would not be returning. Based on interviews conducted and records reviewed, the department received conflicting information.

Based on interviews conducted and records obtained, the allegation that the facility failed to observe change of condition for R1 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. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5