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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803853
Report Date: 03/09/2023
Date Signed: 03/09/2023 04:56:39 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
03/01/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230301093621
FACILITY NAME:MOGRACE RESIDENCEFACILITY NUMBER:
496803853
ADMINISTRATOR:GACEGU, MONICAHFACILITY TYPE:
740
ADDRESS:6299 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7884
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:8CENSUS: 5DATE:
03/09/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alice Wanjirn-CaregiverTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Food Service is not adequate
Resident's incontinent care was not provided as needed
Staff failed to meet resident's medical needs
Neglect/Lack of supervision resulted in resident sustaining a rash
Staff violated residents personal rights
Staff failed to keep the resident's room clean
Medications are not logged appropriately
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) conducted a complaint vist, at approximately 9:00am on 3/9/23, and met with Caregiver Alice; Caregiver Jane arrived later in the morning. There are currently five residents in care.

The LPA reviewed resident files, including medical documentation. LPA reviewed resident medication records. LPA inspected food supply, kitchen, common areas, resident bedrooms, and bathrooms, The LPA conducted interviews with staff, and other interested parties regarding the allegations. The investigation revealed that the food supply is sufficient, and consisted of fresh foods, frozen foods, variety of fruits and vegetales, juice, water, milk, cheese, eggs, breads, canned goods, grains and cereals, and other miscellaneous items during today's visit..
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
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 5
Control Number 21-AS-20230301093621
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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853
VISIT DATE: 03/09/2023
NARRATIVE
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The resident(R1) records has no medical documentation that supports medical needs or care needs were not being met or hadn't been met by the facility. LPA was not provided any other medical documentation that supports this allegation of medical needs not having been met. The resident was seen twice in the ER due to catheter issues, on 1/8/23 and 1/10/23, there are no medical records supporting any neglect of the catheter or care of catheter and/or the neglect of residents incontinent care needs. No medical documentation or supportive documentation of residents needs being neglected resulting in a rash. Per review of resident records the residents medications were logged on a centrally stored medication record as required, it is not known when this was done previously. Per interviews of staff and other interested parties, there was no information provided to support a violation of residents rights, residents being spoken to and/or being treated inappropriately by staff. Per tour of the resident's room it was found to be vacant, and looked as if someone had moved out with a few items here and there but the room was not found to be dirty during today's visit.

Based on the records reviewed, conducted interviews, and LPA's observations, there is no evidence to support the allegations, "Food Service is not adequate, Resident's incontinent care was not provided as needed, Staff failed to meet resident's medical needs, Neglect/Lack of supervision resulted in resident sustaining a rash, Staff violated residents personal rights, Staff failed to keep the resident's room clean, The investigation revealed that there is differing information regarding the allegations are Unsubstantiated.

After the Departments review of records, observations, and interviews, the allegation is UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies cited/No violations.
Exit interview was conducted with the Caregiver Alice Wanjirn.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
03/01/2023 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230301093621

FACILITY NAME:MOGRACE RESIDENCEFACILITY NUMBER:
496803853
ADMINISTRATOR:GACEGU, MONICAHFACILITY TYPE:
740
ADDRESS:6299 COUNTRY CLUB DRIVETELEPHONE:
(707) 843-7884
CITY:ROHNERT PARKSTATE: CAZIP CODE:
94928
CAPACITY:8CENSUS: 5DATE:
03/09/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Alice Wanjirn-CaregiverTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff don't wear masks as required
Medications are not handled appropriately
INVESTIGATION FINDINGS:
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Licensing Program Analyst(LPA) conducted a complaint vist, at approximately 9:00am on 3/9/23, and met with Caregiver Alice; Caregiver Jane arrived later in the morning. There are currently five residents in care.

The LPA reviewed resident files, including medical documentation. LPA reviewed resident medication records. LPA inspected food supply, kitchen, common areas, resident bedrooms, and bathrooms, The LPA conducted interviews with staff, and other interested parties regarding the allegations. The investigation revealed that staff are not wearing masks as required by the Mask Mandate Order. LPA had observed both staff wearing masks during the visit but later on into the visit, both staff had removed their masks and were observed walking around the home, and assisting a resident in the living room.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
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 5
Control Number 21-AS-20230301093621
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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853
VISIT DATE: 03/09/2023
NARRATIVE
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LPA had obtained information from interviews which supported the violation that staff are not wearing masks as required for facility staff. This deficiency will be cited, Personal Rights 87468.1(a)(2), regarding not being in compliance with the required mask mandate-see LIC9099D.,

LPA had observed that medications were pre-poured in advance which is a violation to regulation. Medications must be retained in their original containers. Medication would be taken from medication bottles at the time they are assisting residents with the medication. S1 stated that she has been providing medication assistance by giving the medication from the plastic containers containing the pre-poured medications.. This deficiency will be cited, Incidental Medical and Dental Care 87465(h)(5)-see LIC9099D.

Based on LPA's interviews, review of records, and information LPA obtained, the investigation has revealed that the allegations of "Staff don't wear masks as required and
Medications are not handled appropriately" has been substantiated.

The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited.

Failure to correct deficiencies by POC dates, may result in additional citations, and civil penalties being assessed, including deficiencies re-cited within 12 months.
Exit interview conducted with Caregiver Alice Wanjirn.
Appeal Rights Given.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230301093621
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: MOGRACE RESIDENCE
FACILITY NUMBER: 496803853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/10/2023
Section Cited
CCR
87465(h)(5)
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87465(h)(5) Incidental Medical and Dental Care -(h)The following requirements shall apply to medications which are centrally stored: (5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Facility to ensure that medications are not transferred between containers at any time, per egulation medications are to remain in origianl containers. Licensee to ensure all staff are retrained
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This requirement was not met as evidenced by: LPA observed the resident medications had been prepoured into plastic containers which were to be given to the residents as stated. Medications are to remain in original containers. This is a potenitial risk to health & safety and/or personal rights risk to residents in care.
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in medication procedures, submit proof of training by 3/24/23. Licensee to submit policy and procedures regarding storage of medications, submit plan of correction by 3/10/23.
Type A
03/10/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights 87468.1(a)(2)- Residents in assisted living.-ensuring personal rights are not violated at any time.
This requirement was not met as evidenced by: LPA's observations
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Licensee to ensure the staff wear masks at all times as required by the mask mandate order by Public Health Dept. Submit plan of correction of how the facility
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of two caregivers not wearing masks and walking around the facility and providing needs to a resident in the living room. Staff are to wear masks as required by the Mask Mandate Order from Public Health Dept. This is a risk to health & Safety and/or to personal rights to residents in care
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will be in future compliance with the mask mandate. POC due by 3/10/23.
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: 03/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5