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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804219
Report Date: 12/06/2024
Date Signed: 12/06/2024 08:22:21 PM

Substantiated


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
12/02/2024 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241202162205
FACILITY NAME:VIEWMONT COTTAGEFACILITY NUMBER:
486804219
ADMINISTRATOR:SIMI, ANGELINAFACILITY TYPE:
740
ADDRESS:219 CORKWOOD STREETTELEPHONE:
(707) 287-0118
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 1DATE:
12/06/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Angelina Simi, AdministratorTIME COMPLETED:
03:33 PM
ALLEGATION(S):
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Resident AWOL the facility with no staff supervision
INVESTIGATION FINDINGS:
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 Licensing Program Analyst (LPA) A. Canela arrived unannounced for the purpose of initiating complaint investigation and was greeted by care staff, April Cervantes. Administrator Angelina Simi arrived towards the end of the visit. LPA toured the inside and outside of this facility and went over allegations.

It was alleged resident AWOL the facility with no staff supervision. LPA conducted several interviews with staff, resident R2 and outside source. Investigation revealed that resident R1 who is diagnosed with dementia and per interviews was an eloper, exited the facility on 11/25/2024 with no staff and went over to a neighbors home and attempted to get in. It was also disclosed R1 was observed trying to climb the facilities fence and it was also stated R1 was known by the facility to try to squeeze through the front side gate to get out.

Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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 3
Control Number 21-AS-20241202162205
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: VIEWMONT COTTAGE
FACILITY NUMBER: 486804219
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2024
Section Cited
CCR
87411(a)
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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requiement was not met as evidenced by:
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Facility to send in written plan they understand regulation and how facility will ensure they meet the needs of Dementia residents. Facility to train all staff regarding Care and Supervision, AWOL procedures.
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Based on video clip, interviews and records reviewed: Facility did not ensure supervision of R1, who AWOL'd from the facility without their knowledge on 11/25/2024. R1's Physician's Report(LIC 602) states diagnoses of Dementia & they may not leave the facility unassisted. This is an immediate risk to the health and afety of residents care.
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Written Plan to be submitted by 12/9/2024 and staff training to be submitted to Community Care Licensing (CCL) by POC due date 12/14/2024
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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: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20241202162205
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: VIEWMONT COTTAGE
FACILITY NUMBER: 486804219
VISIT DATE: 12/06/2024
NARRATIVE
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Facility noted R1 with wondering behaviors, Dementia, Agitation and elopement precautions; yet 3 of 5 facility exit doors did not have any auditory or appropriate signal system to alert staff (one door was for R2's exit door, other 2 doors were front and side yard doors, where R1 spent time)

Based on LPA observations and statement received, facility failed to ensure R1s was properly supervised and/or have appropriate preventative measures for resident R1 to exit the facility on their own. R1's medical assessment stated resident may not leave the facility unassisted. The preponderance of evidence standard has been met, therefore the allegations for Resident AWOL the facility with no staff supervision is found to be 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.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Araceli Canela
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3