496804113-8-27-2024-21-AS-BMOS-D9NS54-20241002133343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804113
Report Date: 08/27/2024
Date Signed: 08/27/2024 05:46:21 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
04/03/2024 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240403094147

FACILITY NAME:	FOUNTAINGROVE LODGE		FACILITY NUMBER:	496804113
ADMINISTRATOR:	MOONEY, SHAWN		FACILITY TYPE:	741
ADDRESS:	4210 THOMAS LAKE HARRIS DRIVE		TELEPHONE:	(707) 576-1101
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	173	CENSUS: 99	DATE:	08/27/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Megan Leone-Administrator		TIME COMPLETED:	05:55 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not check on resident every 2 hours.
Staff left resident soiled for an extended period of time
Staff does not ensure resident is assisted with showering needs
Staff does not ensure resident's room is clean and sanitized
Staff did not respond to resident's call in a timely manner
Staff does not provide resident with clean linen
Staff does not ensure resident is provided water

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Alviso conducted a complaint inspection, on 8/27/24 at approximately 9:45am, and met with Megan Leone, Administrator. LPA also met with Michelle Simpson, Health and wellness Director, and Juan Ferrel, Memory Care Director.

LPA reviewed resident (R1) records, facility records, conducted interviews with staff and other related parties. The investigation revealed that R1was admitted 2/25/24, there was a care plan in place upon admission;This is an intial care plan and will updated as needed. Per review of medical hospice documentation there were no documented issues and/or concerns regarding care of R1, while hospice came into the facility to provide care. The care plan would be reviewed and any changes completed and/or care services immediately needed approximately after the first three weeks in care, per reviews with S3 and provided documentation.
Per review of medical documentation, R1 was incontinent, and their care plan noted incontinent care services being provided. LPA reviewed facility records/chart notes on R1, R1 had several falls, no serious injuries noted; R1has had unwitnessed falls per record reviews.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

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 2

Control Number 21-AS-20240403094147

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: FOUNTAINGROVE LODGE	FACILITY NUMBER: 496804113
	VISIT DATE: 08/27/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

R1 is not a one to one staffed resident. R1 is diagnosed with having Parkinsonism and impaired vision per medical documentation. Two of the falls happened while resident was being escorted by staff, staff helped guide resident down to the floor.

Per record reviews, and interviews, R1 was on the schedule for two showers a week and as often as needed. R1's linens and clothing would be laundered on their scheduled day and as often as needed, per staff interviews. Interviews conducted with staff S1, S2, and S3, revealed that residents are all provided hydration, and there is a hydration cart at all times for residents in care. Staff all stated the resident was on two-hour checks for wellness and to check for incontinent care needs. Per interviews with S1, S2, and S3, R1's room was cleaned and bed linen changed every assigned weekday, and as often as needed due to incontinence and/or any other incident/accident. R1's room and/or any area of the unit, would have a work order for rug cleaning if needed due to incontinent accidents. Per staff interviews, if resident called out for any assistance and/or need, the staff would go to the resident and provide services as needed. Staff deny that the resident was ignored and/or neglected by them or any staff. The investigation, review of documentation/records, including medical documentation, interviews with staff, and other parties, provided differing information regarding the allegations. There was no information obtained during the investigation to support that the violations had occurred.

Per the investigation regarding the allegations that "staff left resident soiled for an extended period of time, staff does not ensure resident is assisted with showering needs, staff does not ensure resident's room is clean and sanitized, staff did not respond to resident's call in a timely manner, staff does not provide resident with clean linen, staff does not ensure resident is provided water", there was no information obtained that supported that the violations had occurred.

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 Administrator Megan Leone.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2