496803576-4-22-2025-21-AS-BMOS-DGLNAU-20250512101807

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803576
Report Date: 04/22/2025
Date Signed: 04/22/2025 03:20:46 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
02/13/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250213160356

FACILITY NAME:	SLEEPY HOLLOW ASSISTED LIVING		FACILITY NUMBER:	496803576
ADMINISTRATOR:	ARTHUR ALCONES		FACILITY TYPE:	740
ADDRESS:	3707 SLEEPY HOLLOW DRIVE		TELEPHONE:	(707) 953-2161
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	6	CENSUS: 6	DATE:	04/22/2025
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Arthur Alcones-Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Facility staff are not assisting resident with daily bathing
Facility staff did not seek timely medical attention for the resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 4/22/25 at approximately 10:20:am, and met with Administrator Arthur Alcones. There were two caregivers on duty during the inspection. LPA observed that there was an agency staff providing one to one for a resident in care.

Reporting party alleges that facility staff are not assisting resident with daily bathing, and facility staff did not seek timely medical attention for the resident. LPA reviewed resident, R1's, records and obtained copies that LPA requested, including medical documentation. The LPA interviewed staff and other related parties. The LPA toured the facility, observing resident rooms, bathrooms, and all common areas; The facility was observed to be clean and orderly. The investigation revealed that per interviews and record reviews, R1 has bathing as part of their care plan; R1 is bathed twice a week and as often as needed. Per records and interviews with staff, R1 is incontinent, R1is checked on every two hours, and cleaned and changed as needed. Staff deny that R1 had any skin injury and/or breakdown when checked last before going out per record reviews and medical records, on 2/8/25 R1 had eaten breakfast, and vomited, complaining they felt sick.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

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-20250213160356

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: SLEEPY HOLLOW ASSISTED LIVING	FACILITY NUMBER: 496803576
	VISIT DATE: 04/22/2025

NARRATIVE

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Staff contacted advice nurse regarding their observations of the resident being sick and vomiting, not able to eat. Advice nurse directed them to send resident out to the hospital by 911 to be seen by medical professional. R1 was admitted into the hospital for fecal impaction.

R1 was noted in medical records to have a stage II pressure injury in progress notes documented from 2/12 through 2/14, 2025. There is no exact time and date of when R1 obtained the pressure injury per review of medical records and interviews. Staff deny resident had a pressure injury while in care at the facility. Wound care referral was made by the Doctor for R1, per discharge paperwork of 2/14/25. R1 was discharged back to the care facility. R1 had in-home-health wound care a few times a week; R1’s would has healed and R1’s last day of wound care was 3/25/25, per records. Per review of records, including care plans and staff interviews, R1 has a bathing schedule, twice a week and as often as needed. Per interviews with staff, and other related parties, it was revealed that resident R1 is said to be receiving bathing as needed and incontinent needs are being met. LPA observed R1 to be clean, and facility to be free from urine/feces/foul odors, including R1's room on both inspection dates of 2/18 and 4/22, 2025.

There was no information obtained and/or observed by the LPA to support violations occurred regarding “facility staff are not assisting resident with daily bathing, and facility staff did not seek timely medical attention for the resident”.

Based on the interviews, record/document reviews, and related information obtained during the investigation, the allegations are Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Lead Staff Lorena Lutynski.
Report LIC9099 was left to Lorena Lutynski for the Administrator Arthur Alcones.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025

LIC9099 (FAS) - (06/04)

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