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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803882
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:10:12 PM

Unfounded


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
12/12/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20221212161954
FACILITY NAME:CASA ISABELLA IIFACILITY NUMBER:
486803882
ADMINISTRATOR:VILLEGAS, ART GFACILITY TYPE:
740
ADDRESS:680 SNAPDRAGON PLTELEPHONE:
(707) 344-0839
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: 5DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Art VillegasTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident sustained a fall while in care
Staff falsified personal documents for a resident
INVESTIGATION FINDINGS:
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Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegations. During the course of this investigation this Department has interviewed witnesses and obtained and reviewed documents. The following determinations are made: During follow-up conversations with the Complainant the Department learned that the above captioned allegations do not represent complainants by the Complainant; Although Complainant stated that the resident, R1, fell and that the facility management made false statements to a placing agency, Complainant is not alleging a causal relationship between staff and R1's fall or that any documents were falsified. Complainant has stated that Complainant's statements were misinterpreted. Based upon the documents reviewed and the statements made, this Department has found that the allegations are UNFOUNDED, meaning that the allegations are false and without a reasonable basis. The complaint is DISMISSED.

No citations issued today. Report left.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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 4
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
12/12/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20221212161954

FACILITY NAME:CASA ISABELLA IIFACILITY NUMBER:
486803882
ADMINISTRATOR:VILLEGAS, ART GFACILITY TYPE:
740
ADDRESS:680 SNAPDRAGON PLTELEPHONE:
(707) 344-0839
CITY:BENICIASTATE: CAZIP CODE:
94510
CAPACITY:6CENSUS: 5DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Art VillegasTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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9
Staff overcharged a resident while in care
Staff interfered with a resident’s authorized representative

INVESTIGATION FINDINGS:
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Licensing Program analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegations. During the course of this investigation this Department has interviewed witnesses and obtained and reviewed documents. The following determinations are made: R1’s Admission Agreement dated August 05, 2022, indicates a rate for basic services in the amount of $9,825.00; An unnumbered page attached to the Agreement contains a hand written statement indicating a nightly fee of $25 per hour if certain conditions exist; Records indicate, in addition to basic service fee, R1 was charged $25 per night for the months of Aug and Sept 2023; Facility has not produced records indicating proper written notice with explanation for the additional charges were ever given to R1 as required by Title Twenty-Two regulation 87507. On or about October 20, 2022, facility staff refused to allow R1’s Conservator of the Person and Estate to remove R1 from the facility in order to effect a new placement. Based upon the statements taken and documents reviewed, there is a preponderance of evidence to prove the allegations are true and valid. Therefore, the allegations are SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20221212161954
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: CASA ISABELLA II
FACILITY NUMBER: 486803882
VISIT DATE: 05/16/2023
NARRATIVE
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 The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20221212161954
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: CASA ISABELLA II
FACILITY NUMBER: 486803882
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2023
Section Cited
CCR
87507(g)(3)(B)(1)
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87507(g)(3)(B)(1) Admission Agreements. A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. ***This requirement has not been met as evidenced by: R1 was charged in excess of fee for basic services without
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Administration shall submit a revised accounting of fees due from R1 which includes the basic fee of $9,825 plus any fee for supplies along with proposed amount of refund due to R1. Accounting is to be submitted to CCL by POC date and is subject to approval by CCL in order to clear the deficiency.

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proper notice and explanation as required by regulation. This posed an immediate risk to R1’s personal rights.
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Type A
05/23/2023
Section Cited
CCR
87468.1(a)(9)
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87468.1(a)(9) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following person To have communications to the licensee from their representatives answered promptly and appropriately. ***This requirement has not been met as evidenced by: On or about Oct 20, 2022,
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Administration shall review the Personal rights sections of Title Twenty-Two regulations and submit a signed and dated declaration to CCL by POC date in order to clear the deficiency. Declaration to address the rights review and commitment going forward to comply with the regulations.
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R1’s Conservator was told that the Conservator could not remove R1 from the facility. This posed an immediate risk to the personal rights of R1

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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: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4