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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803588
Report Date: 11/14/2025
Date Signed: 11/14/2025 02:24:16 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
10/22/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251022160949
FACILITY NAME:COUNTRY ROSE ASSISTED LIVINGFACILITY NUMBER:
496803588
ADMINISTRATOR:ARCHER, LEAHFACILITY TYPE:
740
ADDRESS:2273 WEST HEARN AVENUETELEPHONE:
(707) 495-0801
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:6CENSUS: 4DATE:
11/14/2025
UNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Rosie Ascencio (Lead Staff)TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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-Facility did Not Meet Required Reporting Requirements.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Rosie Ascencio, Lead Staff.

There was an allegation of facility did not meet the required reporting requirements. The Reporting Party has disclosed that R1 went to the emergency room on 10/11/2025 or 10/12/2025 due to experiencing vomiting for two straight days, but there was no supporting evidence that the facility made a report about R1’s hospitalization to the Department. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The Department will review the information obtained to determine if any further action is needed.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
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-20251022160949
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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2025
Section Cited
CCR
87211(a)(1(D)
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Type B - 87211(a)(1)(D) Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by:
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Licensee agrees to submit incident reports for R1’s current incident and conduct a staff training pertaining to reporting requirements submitting IR's and training roster with topics covered to CCL by POC.
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Based on LPAs interviews and record review the facility failed to submit an incident report for R1 incident which required hospitalization which poses a potential health and safety 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: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
10/22/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20251022160949

FACILITY NAME:COUNTRY ROSE ASSISTED LIVINGFACILITY NUMBER:
496803588
ADMINISTRATOR:ARCHER, LEAHFACILITY TYPE:
740
ADDRESS:2273 WEST HEARN AVENUETELEPHONE:
(707) 495-0801
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:6CENSUS: 4DATE:
11/14/2025
UNANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Rosie Ascencio (Lead Staff)TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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-Facility is Violating Resident's Personal Rights.
-Facility is Not Meeting Resident's Care Needs.
-The facility is not being clean and sanitary at all times.
-Facility is not meeting the Recommended Dietary Allowances for Residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and delivered findings regarding the allegation listed above and met with Lead Staff, Rosie Ascencio.

The first allegation is about facility violating resident's personal rights. Per reporting party, resident (R1) experiences frequent episodes of vomiting due to illness, they won’t help R1 dial the phone to arrange their medical appointments with their responsible party, the facility is not allowing residents to make phone calls after 6:00pm, they make residents go to bed at 8:00pm. Also, staff (S1) is targeting R1 by yelling at them, stating that R1 is a troublemaker, listening to R1’s phone conversations via cameras, and telling R1 to stop telling lies to outside parties making R1 cry. According to the reporting party, the licensee disregarded their concerns and implied that R1 was a liar about the situation. On 10/28/25, LPA conducted a 10-day visit, reviewed records, made observations, interviewed residents and staff. Based on interviews conducted with residents (R1, R2 & R3), it indicates that residents feel that their personal rights are respected providing information about their freedom and choice to receive phone calls or visitors at any time. Continues on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20251022160949
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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588
VISIT DATE: 11/14/2025
NARRATIVE
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Continued from LIC9099A...
R1 stated that they get assistance from all staff when needed and did not provide any supportive information regarding threats made by staff to residents in care. Interviews conducted by LPA with staff (S1 & S2) indicated that they are assisting residents when they need to make a phone call to anybody, they help by locating the contact name of the person that they want to call, then they leave the room to allow them to have privacy and they ensures that residents are able to go to bed at their desire time. Although staff confirm that they use a paging system, they showed to LPA that the pager’s sounds like a bell only, and is not able to reproduce video nor audio, which could result in a violation of personal rights of residents in care. Interviews conducted with outside parties (I1) confirmed that R1 has a cellphone that they use to communicate anytime with them, at times if R1 doesn’t answer the phone due to their mental challenges, then the facility staff helps them to dial up. Based on records review of the facility visitation policy, the facility visiting hours are between 10am-7pm daily, offers telephone services as follow: “family members and friends are able to contact the facility by phone, fax or email to communicate with the resident or the resident can use the house phone to contact family or friends”. Based on interviews and records review, LPA is unable to determine if a violation of personal rights occurred at a prior date. A finding that the allegation of facility violating resident's personal rights is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Regarding allegation of facility not meeting resident’s care needs. According to the reporting party, resident (R1) experience frequent vomiting due to illness, but the facility staff hand them a bucket instead of assisting R1 to the bathroom, night shift staff are not responding to R1’s signal calls which resulted in R1 sustaining falls and R1 has been left on the floors for extended periods of time after nighttime falls. On 10/28/25, During the tour of the facility, LPA observed two staff were on shift assisting residents with their needs, there was a pager motion sensor alarm located in R1’s bedroom by their bedside, the device is used as an alarm to alert staff if R1 moves out of their bed, which is in the facility kitchen. During the tour of the physical plant the bathrooms, resident’s rooms, facility kitchen and common areas appeared clean, free of odors and sanitary. There were some areas that could be improved with enhanced cleaning including some areas of the kitchen, but no flies were observed.
Continues on LIC9099C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20251022160949
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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588
VISIT DATE: 11/14/2025
NARRATIVE
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Continued from LIC9099C...
Based on interviews conducted with residents (R1, R2 & R3), it is confirmed that staff are providing assistance with their needs and there were no concerns raised by residents in care. Interviews conducted by LPA with staff (S1 & S2) confirm that due to constant episodes of vomiting, they have facilitated a small bucket for R1 to use, but they ensured that they are assisting R1 timely and they use a paging system to alert them when R1 needs assistance. According to interviews conducted by LPA with outside parties (I1) determines that they had a meeting with the Licensee days prior to LPA’s visit to the facility, where it was discussed how to accommodate R1’s care needs by using a bedside commode to prevent R1’s frequent falls, but R1 refuses to use the commode when they need to use the bathroom, they also acknowledge the use of the paging system and they are in agreement of their utilization as an additional effort to help to meet R1’s needs, but they denied that R1 has been left on the floor for extended periods of time. However, LPA was unable to review residents’ (R1, R2, R3 & R4) care plans because records were not available at the facility for LPA's review as indicated by regulation. LPA will address resident’s records availability in case management. On 10/30/25, based on records provided by the Licensee of R1’s care plan dated 9/19/25 determines that R1 needs assistance with activities of daily living, which includes a bedside commode and bed alarm to alert staff when R1 needs assistance to use the bathroom, which is confirmed by R1’s physician report dated 9/16/25. Based on LPA’s observation, interviews and records review, there is no supporting information that the facility is not meeting resident’s care needs. A finding that the allegation of facility not meeting resident’s care needs is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Another allegation of facility is not being clean and sanitary at all times. Per reporting party, the facility has been observed extremely dirty and that flies are abundant (unknown dates). On 10/28/25, LPA conducted a 10-day visit to the facility, made observations, reviewed records and interviewed residents in care. LPA/Licensee toured the facility inside and outside and made observations.
Continues on LIC9099C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20251022160949
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: COUNTRY ROSE ASSISTED LIVING
FACILITY NUMBER: 496803588
VISIT DATE: 11/14/2025
NARRATIVE
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Continued from LIC9099C...

Based on LPA’s interviews with residents (R1, R2 & R3) there were no concerns raised about the cleanliness of the house. LPA has determined and confirmed that although the facility appeared to be clean and in a sanitary condition during today’s inspection, LPA is unable to determine if an area of the facility was unclean or unsanitary condition at a prior date. A finding that the allegation of facility is not being clean and sanitary at all times is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Lastly, the facility does not meet recommended dietary allowances for residents. Per reporting party, the facility staff is not feeding R1 enough food, ignoring R1’s requests for tea or coffee. On 10/28/25, LPA made observations and conducted interviews with residents in care. LPA toured the kitchen area with Licensee, including kitchen closet where at least one week of perishable food was observed and the refrigerator had at least two days of non-perishable foods. Based on records review, the licensee provided receipts for the month of October 2025 from various retail stores dated: 10/1/2025 on the amount of $154.53, 10/8/25 on the amount of $241.70, 10/10/25 on the amount of $150.79 and 10/13/25 on the amount of $150.90 including food items observed during tour of the kitchen area which confirmed that there were a supply of ingredients to make items on or like what was on the menu is available for residents in care. Interviews conducted by LPA with residents (R1, R2 & R3) and staff (S1 & S2) revealed that some residents prefer certain items over others, especially spicy foods, but according to residents all staff can provide a different food option for them, but interviews conducted did not necessarily indicate that food service was inadequate. Based on records review, five out of five resident’s (R1, R2, R3, R4 & R5) physician reports and care plans do not indicate that any resident has a specialized diet requirement on file. LPA learned based on interviews with staff and residents, information was not provided to support that violation occurred regarding facility staff does not meet recommended dietary allowances for residents. A finding that the allegation of the facility is not meeting recommended dietary allowances for residents is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6