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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486801218
Report Date: 06/19/2025
Date Signed: 06/19/2025 12:10:06 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
03/21/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20250321094711
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:
06/19/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lourdes Gadia, Designated Responsible PartyTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not administer medication as prescribed by doctor
INVESTIGATION FINDINGS:
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On 06/19/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250321094711 investigation findings regarding the above allegations and met with Lourdes Gadia, Designated Responsible Party (DRP). Reporting Party (RP) alleges that the facility staff did not administer medication as prescribed by doctor for Resident 1 (R1).

LPA Florio conducted 10-day complaint investigation visit on 03/27/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through an interview with the House Manager (HM) and progress notes dated 03/15/2025-03/20/2025 that R1 refused medications on more than one occasion, R1 liked to count their pills on a napkin on the bedside table and take them when ready, and sometimes this resulted in pills being found in the bed.

Continued on LIC9099C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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 3
Control Number 21-AS-20250321094711
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: 06/19/2025
NARRATIVE
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Continued from LIC9099...

Further, the facility's staff training manual section on their medication administration policy, states "watch the resident take the medication. Stand by until medication is swallowed." Based on the above information, the facility did not administer R1's medications in accordance with their policy, per regulation, or as prescribed by their doctor.

Based on interviews conducted and records obtained, the allegation that the facility staff did not administer medication as prescribed by doctor 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).

Exit interview conducted with DRP, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250321094711
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: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care: 87465(a)(4) The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by:
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Licensee to submit proof of retraining with all staff on administration of medications in accordance with regulation and the facility's policy. Additionally, this training shall include a review of the required notification procedures when a resident...
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Based on interviews conducted and documents obtained for R1, the facility staff did not ensure that R1 took their medications as directed by their doctor which poses/posed a potetnial health, safety, and/or personal rights violation to persons in care.
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...refuses medications, including an update to the facility's policy which accurately reflects regulatory reporting requirements to CCL by POC due date of 07/18/2025.
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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: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3