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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804154
Report Date: 11/06/2024
Date Signed: 11/06/2024 10:26:55 AM

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
08/26/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20240826170955
FACILITY NAME:LOVING HEARTS CARE HOME 111FACILITY NUMBER:
486804154
ADMINISTRATOR:DEVERA, ROSE MARIE B.FACILITY TYPE:
740
ADDRESS:702 MUSTANG CTTELEPHONE:
(707) 864-6683
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 6DATE:
11/06/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Rose Devera, LicenseeTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident's needs are not being met.
Insufficient staffing.
INVESTIGATION FINDINGS:
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On 11/06/2024, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint investigation findings regarding the above allegations and met with Licensee, Rose Marie Devera. Reporting Party (RP) alleges that Resident 1's (R1’s) needs are not being met and that the facility has insufficient staffing which RP says have resulted in facility staff declining R1’s requests for assistance with transferring to their wheelchair to be taken outside or to shower.

LPA conducted 10-day complaint investigation visit on 08/28/2024 and obtained documents, made observations, and conducted interviews with Staff (S1), Staff 2 (S2), Licensee, R1 Resident 2 (R2), and Resident 3 (R3). Based on LPAs interviews, LPA received conflicting information regarding the above allegations.

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

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
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-20240826170955
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: LOVING HEARTS CARE HOME 111
FACILITY NUMBER: 486804154
VISIT DATE: 11/06/2024
NARRATIVE
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Continued from LIC9099...

On 8/28/2024 LPA received copies of R1’s pre-placement appraisal, IPP, and care plan documentation from Licensee which confirm that R1 has a known, documented history of refusing transfer assistance to go outside or to shower as well as physically and verbally abusive behavior towards care staff. Additionally, on 8/28/2024, LPA received a copy of the facility’s LIC500 Staff Roster & work schedule showing that the facility typically has 2 staff working during the day shifts and 1-2 staff working the evening shift, depending on residents' care needs. The facility is licensed for a maximum of 6 residents.

Based on record review, interviews conducted, and observations made, the allegations of resident's needs are not being met and insufficient staffing are UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2