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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803839
Report Date: 11/03/2022
Date Signed: 11/03/2022 06:39:56 PM

Unsubstantiated


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
07/18/2022 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220718080450
FACILITY NAME:FAMILY HOUSEFACILITY NUMBER:
496803839
ADMINISTRATOR:GUZMAN ESTELITA, MARIA VFACILITY TYPE:
740
ADDRESS:6084 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7367
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 5DATE:
11/03/2022
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Estelita Guzman-AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Staff do not provide proper medication assistance to resident
Staff yells at residents
Staff do not maintain a conformable facility temperature for residents
Staff do not provide proper incontinence care to the resident
Staff did not provide needed services to the resident regarding resident's meals
Food preparation area is unsanitary
INVESTIGATION FINDINGS:
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Licesing Program Analyst (LPA) Alviso conducted a complaint inspection, on 11/03/2022 at approximately 3:35pm, and met with Administartor Emelita Guzman. LPA observed two other staff/caregivers on duty during the inspection.

The LPA toured the facility on each inspection during the investigation. The LPA reviewed resident records, facility records, interviewed facility staff, and other interested parties. The investigation revealed that there was differing information obtained from review of files, and interviews with staff and other interested parties, and the inspection of the facility. There was no information obtained that provided sufficient support regarding the above allegations.

LPA observed the kitchen to be clean and orderly. LPA observed the facility to be at a comfortable temperature for residents in care, during LPA's unannounced inspections.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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 4
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
07/18/2022 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20220718080450

FACILITY NAME:FAMILY HOUSEFACILITY NUMBER:
496803839
ADMINISTRATOR:GUZMAN ESTELITA, MARIA VFACILITY TYPE:
740
ADDRESS:6084 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7367
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:6CENSUS: 5DATE:
11/03/2022
UNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Estelita Guzman-AdministratorTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Visitors were denied visitation with a resident in care
INVESTIGATION FINDINGS:
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Licesing Program Analyst (LPA) Alviso conducted a complaint inspection, on 11/03/2022 at approximately 3:35pm, and met with Administartor Emelita Guzman. LPA observed two other caregivers on duty during the inspection.
The LPA reviewed resident records, facility records, interviewed facility staff, and other interested parties. The investigation revealed that a resident's visitor(s) were denied visitation with the resident. This deficiency will be cited, 87468.1(a)(11), see LIC9099D.

Based on record reviews, and interviews during this investigation, the allegation of "Visitors were denied visitation with a resident in care" is substantiated. 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.
Exit interview conducted.
Appeal Rights Given to the Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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 4
Control Number 21-AS-20220718080450
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: FAMILY HOUSE
FACILITY NUMBER: 496803839
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited
CCR
87468.1(a)(11)
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87468.1-Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (11)To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.This requirement was not met as evidencced by:
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Licensee to ensure that residents rights are not violated at any time. The resident may have visitation per regulations.Please hold an in-service with facility staff on resident personal rights and ensuring they are not violated. Submit proof of training by 11/8/22.
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LPA's investigation, per record reviews, and interviews with staff, the resident visitors were denied visitation with the resident. This is a violation to personal rights of the resident(s) in care.
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Submit plan of correction and Licensee/Administrator to submit written self- certification of their understanding of resident visitation rights/personal rights of the resident. Submit POC by 11/4/22.
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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: 11/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 21-AS-20220718080450
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: FAMILY HOUSE
FACILITY NUMBER: 496803839
VISIT DATE: 11/03/2022
NARRATIVE
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LPA observed resident in care to be clean, and observed staff helping feed the resident as needed. Resident may also feed themselves at times.Resident does have a care plan in place, including professional medical care services that are being provided by Hospice Agency. Medication assistance is provided, and resident is given water/liquids to swallow pills. Resident on incontinent services plan per review of records. Resident is observed by hospice agency staff and there are no noted concerns in hospice progress notes regarding resident care needs not being met. Per interviews with staff, and other interested parties there is differing information regarding staff yelling at the resident(s)-no sufficient information obtained to support the allegations.

Based on record reviews, interviews conducted, and information obtained, there is no evidence to support the violations occurred. The allegations of "Staff do not provide proper medication assistance to resident , Staff yells at residents , Staff do not maintain a conformable facility temperature for residents, Staff do not provide proper incontinence care to the resident, Staff did not provide needed services to the resident regarding resident's meals, Food preparation area is unsanitary" are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited regarding these allegations.
Exit interviews were conducted with Administrator Estelita Guzman.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4