486804162-2-27-2026-21-AS-BMOS-DRSP4A-20260302095843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804162
Report Date: 02/17/2026
Date Signed: 02/27/2026 03:39:47 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
10/22/2025 and conducted by Evaluator Julie Florio

COMPLAINT CONTROL NUMBER: 21-AS-20251022103435

FACILITY NAME:	PACIFIC GARDENS ON HAWKESBURY		FACILITY NUMBER:	486804162
ADMINISTRATOR:	BERNARDINO, KRISTINE		FACILITY TYPE:	740
ADDRESS:	120 HAWKESBURY WAY		TELEPHONE:	(760) 296-7562
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	6	CENSUS: 5	DATE:	02/17/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Mary Grace Defeo, Designated Responsible Party		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not assist residents with incontinence needs.
Staff are not following resident's dietary needs.
Staff did not ensure resident was fed an adequate amount of food.
Staff did not empty resident's urinal.
Staff left resident's in a soiled diaper for a long period of time.

INVESTIGATION FINDINGS:

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***AMENDED COMPLAINT INVESTIGATION FINDINGS***

On 02/27/2026, at approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct further investigation and deliver amended complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20251022103435, which was received by Community Care Licensing (CCL) on 10/22/2025. Reporting Party (RP) claims the above allegations. LPA met with Mary Grace Defeo, Designated Responsible Party (DRP).

On 10/27/2025, LPA conducted a 10-day complaint investigation. During the visit, LPA obtained documents, made observations, and conducted interviews. Per an interview conducted with DRP during...

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20251022103435

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: PACIFIC GARDENS ON HAWKESBURY	FACILITY NUMBER: 486804162
	VISIT DATE: 02/17/2026

NARRATIVE

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***AMENDED COMPLAINT INVESTIGATION FINDINGS***

Continued from LIC9099...

the visit, a subsequent interview conducted with DRP on 02/12/2026, and an interview conducted with RP on 02/12/2026, both stated that Resident 1 (R1) moved in around 7pm at night on 10/20/25 and moved out between 1:00-2:00pm on 10/21/2025.

RP stated R1 was not offered breakfast foods but rather was offered dinner foods the morning of 10/21/2025. RP also stated they changed R1 on their own but admitted not notifying facility staff that R1 needed to be changed or requesting assistance. RP stated that R1 did not incur any change of condition including compromised or decreased skin integrity as the result of their stay at the facility. RP further stated that they observed commodes and urinals full and smelled urine in the facility. Per interviews with DRP, facility staff check on each resident every couple of hours and this includes checking their briefs, commode, and urinals which are then changed and/or emptied as needed.

During today's inspection, LPA completed a walk through of the facility, conducted interviews, and made observations. LPA found the facility to be clean, sanitary, and free from odors. LPA observed an empty bedside commode and urinal in two separate resident rooms. Based on interviews conducted with DRP and with residents R1, R2, and R3, residents are offered eggs, toast, pancakes, sausage, fruit, oatmeal, and similar foods for breakfast each day. Each stated they are checked on every couple hours where they are assisted with changing their briefs and urinals are emptied if indicated. LPA received conflicting information regarding food, incontinent care, and bedside care provided to R1 and other residents in care..

Based on interviews conducted, observations made, and records obtained, the listed allegations ARE 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 DRP, whose signature on form confirms receipt of document(s).

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2026

LIC9099 (FAS) - (06/04)

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