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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496801090
Report Date: 04/18/2023
Date Signed: 04/18/2023 02:40:53 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
12/12/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221212114408
FACILITY NAME:HANNA HOUSE RIDLEYFACILITY NUMBER:
496801090
ADMINISTRATOR:HANNA, DAVIDFACILITY TYPE:
740
ADDRESS:1840 RIDLEY AVENUETELEPHONE:
(707) 591-0980
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:28CENSUS: 28DATE:
04/18/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:David Hanna-AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso, conducted a complaint visit, approximately 9:00am 4/18/2023 , and met with Administrator David Hanna, and Resident Care Coordinator(RCC) Karrie Hanna.

LPA reviewed twelve(12) resident files, and six(6) staff files; The LPA conducted interviews with staff, and other interested/related parties, regarding the allegation(s). The LPA toured the facility on both, 12/15/22, and today 4/18/23. The LPA inspected resident rooms, kitchen, dining area, and food supply. The investigation revealed that resident(R1) has an area up on the ceiling in their bedroom that shows the paint is affected by some moisture in this area; The LPA also observed large patches of mold which were found under some album covers that were hanging on the wall. The Administrator stated that years ago this area had a problem but it was repaired, and Administrator stated to the LPA it is possibly a roof problem.

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

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
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 6
Control Number 21-AS-20221212114408
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: HANNA HOUSE RIDLEY
FACILITY NUMBER: 496801090
VISIT DATE: 04/18/2023
NARRATIVE
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The Administrator stated to the LPA that they will immediately start addressing the problem of the ceiling and wall having a moisture/water problem. The LPA did not observe any leaking water on the ceiling or the wall but did observe the mold and ceiling paint showing color change, spotting, water damage/moisture issues. The RCC had staff come in and start cleaning the wall in resident's(R1's ) room to disinfect and clean the mold.

Based on LPA observations, interviews, and review of records, the investigation has revealed that the allegation of "Facility is in disrepair" has been substantiated.

LPA observing a moisture problem/water damage on the ceiling in R1's room, including observation of mold growing on the resident's wall under album covers that were hanging. LPA obtained photos. Due to the substantiation of the allegation, a deficiency will be cited today, Maintenance and Operation 87303(a) The facility shall be clean, safe, sanitary, and in good repair at all times; Maintenance shall include provision of maintenance services and procedures for safety and well-being of residents, and others, 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 the Administrator David Hanna.
Appeal Rights Given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20221212114408
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: HANNA HOUSE RIDLEY
FACILITY NUMBER: 496801090
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation 87303(a) The facility shall be clean, safe, sanitary, and in good repair at all times; Maintenance shall include provision of maintenance services and procedures for safety and well-being of residents, and others. This requirement was not met as evidenced by:
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Licensee/Administrator Davd Hanna to submit plan of correction in repairing the water leak/moisture problem, roof repairs that is causing water damage to the ceiling and wall in resident(R1's )room.
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LPA observing a moisture problem on the ceiling in R1's room, including observation of mold growing on the resident's wall under album covers that were hanging.This is a risk to the health & safety and/or a risk to personal rights of the
resident(s). LPA obtained photos.
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Administrator stated to the LPA that they will be contacting a roofing company and having the roof inspected and repaired. Administrator stated they will immediately clean the wall and put a tarp on the roof till repaired. Will submit POC due 5/2/23.
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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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
12/12/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20221212114408

FACILITY NAME:HANNA HOUSE RIDLEYFACILITY NUMBER:
496801090
ADMINISTRATOR:HANNA, DAVIDFACILITY TYPE:
740
ADDRESS:1840 RIDLEY AVENUETELEPHONE:
(707) 591-0980
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:28CENSUS: 28DATE:
04/18/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:David Hanna-AdministratorTIME COMPLETED:
02:40 PM
ALLEGATION(S):
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Staff refuse to treat resident's scabies condition
Staff hits resident in care
Staff yell at resident in care
Residents in care are not assisted with their showers
Residents are not provided proper food service
Staff withholds resident's mail
Staff do not provide proper medication assistance to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso, conducted a complaint visit, approximately 9:00am 4/18/2023 , and met with Administrator David Hanna, and Resident Care Coordinator(RCC) Karrie Hanna.

LPA reviewed twelve(12) resident files, and six(6) staff files; The LPA conducted interviews with staff, and other interested/related parties, regarding the allegations. The LPA toured the facility on both, 12/15/22, and today 4/18/23. The LPA inspected resident rooms, kitchen, dining area, and food supply. The investigation revealed that there were residents that were seen by a medical professional in person, and by video appointment, due to possibly having been infected with scabies. The residents that were infected with scabies were treated with prescribed medication; There were some residents that were found to have symptoms and the Physician had them treated with prescribed medication.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20221212114408
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: HANNA HOUSE RIDLEY
FACILITY NUMBER: 496801090
VISIT DATE: 04/18/2023
NARRATIVE
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Per investigation, it was revealed that no residents had bed bugs and/or lice in the facility. Per investigation, LPA found that residents' who were assessed to have scabies and/or had symptoms were by staff, by a medical professional, and treatment was provided per Doctor's orders.

Per interviews, staff, six (6) out of six(6), deny that they hit and/or yell at the residents in care; Staff stated to the LPA that they have not observed another staff hit and/or yell at residents of the facility. The LPA discussed with facility staff, personal rights of residents in care, and ensuring residents rights are not violated.

Per interviews and record reviews, it was revealed that residents have shower schedules, and are also showered as needed due to an emergency and/or if an accident happens. If a resident doesn't take their showers at the scheduled time due to saying no and/or for any other reason, the shower can be provided as soon as possible that day or the next day. Residents may shower as often as needed but if needing assistance with bathing staff will fit the resident in as soon as possible, that day and/or the next day due to the shower schedule. Some residents shower once a week and others a few times a week, and as often as needed.

The LPA conducted interviews with staff(5) and other interested parties. Per investigation, it was revealed that the facility had a sufficient supply of food to provide meals to residents. The food supply contains meats, vegetables, fruits, and grains, that need to be cooked for resident meals. There was also eggs, cheese, cereals, fruits, drinks, and milk for resident meals.

Per investigation and interviews with staff, S 1 and S2, all resident mail is provided to residents. The LPA discussed resident's personal rights with staff, S1 and S2, and this includes the right to resident's having their personal mail provided to them, unopened.
Staff S1 and S2 stated their understanding of the above regarding a resident's personal mail, and resident's right to it.

Continued on LIC9099C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20221212114408
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: HANNA HOUSE RIDLEY
FACILITY NUMBER: 496801090
VISIT DATE: 04/18/2023
NARRATIVE
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Per review of resident records(R1), interviews with staff, and other interested parties, it was revealed that all medications, and over the counter medications and supplements provided to the resident, are prescribed by the Physician. There are no medications allowed to be retained on-site and/or provided to the resident without a Physician's order. The LPA discussed Incidental Medical and Dental Care regulations with all parties, discussing the requirement of having a Physician's Order for all medications, and over the counter medications, including supplements. Without the Physician's order a facility staff can't have the medication and provide it to a resident/residents. Per review of records all medications prescribed are provided per Doctor's Orders to resident(R1).

Based on LPA's investigation, record reviews, and interviews with staff, and information obtained during interviews with other related parties, there was no information obtained to support that a violation occurred, the allegations of "Staff refuse to treat resident's scabies condition, Staff hits resident in care, Staff yell at resident in care, Residents in care are not assisted with their showers, Residents are not provided proper food service, Staff withholds resident's mail, Staff do not provide proper medication assistance to resident in care' are unsubstantiated.

Based on observations, record reviews, and interviews with staff and other parties, there is insufficient information to support that violations occurred. Although the allegations 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 allegations are Unsubstantiated.

No deficiencies cited.
Exit interview conducted with Licensee/Administrator David Hanna.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6