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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800968
Report Date: 11/19/2024
Date Signed: 11/19/2024 01:38:25 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
11/13/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241113081905
FACILITY NAME:WILD ROSE CARE HOMEFACILITY NUMBER:
496800968
ADMINISTRATOR:GARCIA, MARYFACILITY TYPE:
740
ADDRESS:1921 QUAIL RUNTELEPHONE:
(707) 571-1910
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 6DATE:
11/19/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mary Garcia-AdministratorTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff raised thier voice at the resident, and pushed them out of the kitchen
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso, conducted a complaint inspection, approximately 9:45am on 11/19/24, and met with Mary Garcia, RN, Licensee/Administrator.

LPA reviewed resident (R1) records, staff records, and facility records. LPA obtained copies of requested documents. LPA interviewed staff, S1, and obtained other information from other related parties. The reporting party alleges that staff raised their voice at the resident and pushed them out of the kitchen. The investigation revealed that there was additional information reported by staff S2 to staff S1 of a resident incident that had occurred when R1 kept going into the kitchen area where the stove was hot, staff were cooking. S2 stated they may have been observed to have raised their voice when telling the resident they had to get out of the kitchen; S2 stated to S1 that they had put their hands on R1's back and pushed them out of the kitchen due to being scared they were going to touch the stove. S2 stated the staff had kept moving the resident down the hall towards their room so resident could use the bathroom,S2 still had their hands on resident's back. R1 became agitated and upset with staff, refused to continue ambulating, and slid down to the floor in a sitting position. R1 was assessed by staff, staff observed no injuries, and resident was assisted up to a standing position. Resident was assisted to their room by staff.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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-20241113081905
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: WILD ROSE CARE HOME
FACILITY NUMBER: 496800968
VISIT DATE: 11/19/2024
NARRATIVE
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S1 stated that they discussed with S2, and other staff, facility's dementia care policy, and rights of the residents. S1 stated that they are addressing the situation with S2 regarding caregiver responsibilities, caregiver expectations, and S2's employment status. S1 stated they will provide all documents regarding the above to the LPA.

Per LPA's observations, review of records, interviews with staff, and obtained information, there is sufficient information obtained to support a violation did occur, the allegation of "staff raised their voice at the resident, and pushed them out of the kitchen " is Substantiated. This deficiency will be cited, 87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities-In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.
Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with Mary Garcia RN, Administrator/Licensee.
Appeal Rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241113081905
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: WILD ROSE CARE HOME
FACILITY NUMBER: 496800968
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities- To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per LPA's investigation, S2 told S1 of a resident incident that had occurred when R1 kept going into the kitchen area where the stove was on/hot, staff
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CORRECTED-LICENSEE/ADMINISTRATOR HELD IN-SERVICE TRAININGS WITH ALL STAFF, INCLUDING S2 REGARDING PERSONAL RIGHTS OF RESIDENTS IN CARE, AND FACILITY'S DEMENTIA CARE/REDIRECTION POLICY.
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were cooking. S2 stated they may have been observed to have raised their voice when telling the R1 they had to get out of the kitchen; S2 stated to S1 that they had put their hands on R1's back and pushed them out of the kitchen due to being scared they were going to touch the stove. S2 kept hands on resident's back as they moved them down the hallway. This is a personal rights violation for resident (s) in care.
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LICENSEE PROVIDED DOCUMENTATION REGARDING PLAN OF CORRECTION. POC CLEARED.
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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: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3