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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804162
Report Date: 02/17/2026
Date Signed: 02/27/2026 03:43:08 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
10/22/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20251022103435
FACILITY NAME:PACIFIC GARDENS ON HAWKESBURYFACILITY NUMBER:
486804162
ADMINISTRATOR:BERNARDINO, KRISTINEFACILITY TYPE:
740
ADDRESS:120 HAWKESBURY WAYTELEPHONE:
(760) 296-7562
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 5DATE:
02/17/2026
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary Grace Defeo, Designated Responsible PartyTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff do not ensure residents are given privacy
Unqualified staff attempted to administer morphine to a resident in care
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 that visit, LPA toured the facility, made observations and conducted interviews. LPA did not observe a privacy screens being utilized in the facility for residents in shared rooms, nor was facility able to provide proof of any such items.

Continued on LIC9099C...
Substantiated
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)
Page: 1 of 3
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...

Per an interview conducted with DRP during that visit, a subsequent interview conducted on 02/12/2026, and an interview conducted with RP on 02/12/2026, LPA received consistent information from both parties that no privacy shield was put in place to ensure privacy for Resident 1 (R1) while having their briefs changed or receiving any sort of bedside care in their shared room. Facility has since purchased portable privacy screens and agrees to utilize them in shared rooms when providing any sort of care moving forward.

During the above mentioned interviews with DRP and RP, LPA received consistent information from both parties that that Staff 1 (S1) drew up R1's PRN narcotic and attempted to hand it to RP to administer to R1. Additionally, on 02/27/2026, LPA conducted a phone interview conducted with a representative from the third party Hospice agency which revealed that the narcotics prescribed for R1 were not delivered to the facility in pre-filled syringes for facility staff to assist R1 with administering the narcotic to themselves as required per regulation. Based on interviews conducted and records obtained, S1 should have contacted the Hospice agency nurse to come to the facility to assist R1 with drawing up and and administering their narcotics.

Based on observations made and interviews conducted, the allegations that staff do not ensure residents are given privacy and unqualified staff attempted to administer morphine to a resident in care are 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.

Deficiencies are cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted with DRP, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to DRP.
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)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/02/2026
Section Cited
CCR
87633(j)(1)
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Hospice Care of Terminally Ill Residents 87633(j)(1) ...[F]acility staff, other than appropriately skilled health professionals, shall not perform any health care procedure that under law may only be performed by an appropriately skilled professional.
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Licensee to self-certify that all staff have reviewed the regulation and have been retrainied on the proper administratrion of narcotics to CCLD by POC due date of 03/02/2026.
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This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not ensure that R1's morphine was administrered by an appropriately skilled professional. This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.
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Type B
03/17/2026
Section Cited
CCR
87468.2(a)(1)
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Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance....

This requirement is not met as evidenced by:
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Licensee to submit proof to CCLD that a privacy barrier has been implemented in the facility to use in shared rooms while performing care to residents in order to ensure their privacy by POC due date of 03/17/2026.
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Based on observations made and interviews conducted, Licensee did not ensure that R1 received a reasonable level of personal privacy while having their briefs changed. This poses a potential Health, Safety and/or Personal Rights risk to residents 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: 02/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3