<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804239
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:18:35 PM

Substantiated


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
11/08/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241108132545
FACILITY NAME:BLUEBELL MANORFACILITY NUMBER:
496804239
ADMINISTRATOR:SOLOMON BANAFACILITY TYPE:
740
ADDRESS:1997 BLUEBELL DRIVETELEPHONE:
(707) 800-2522
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 5DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bana Solomom-AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure resident is provided a shower mat


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 1/29/2025 at approximately 10:00am, and met with Bana Solomon, Administrator/Licensee.

LPA reviewed resident files, staff files, and conducted interviews with staff (S1, S2, S3) and other related parties. LPA toured the facility with staff. Reporting party alleges that “staff does not ensure resident is provided a shower mat”.

Per interviews with staff and other related parties on 11/13/24, the investigation revealed that shower mats had been removed from showers in the facility, for an unknown time frame, and staff were directed to use towels on the shower floor when showering residents. Per interviews with staff and other related parties, non-slip mats had recently been brought back into the facility within the last few weeks from the LPA's inspection, 11/13/24. LPA discussed regulations regarding maintenance and operation, and resident rights/personal rights with staff interviewed.
Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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 5
Control Number 21-AS-20241108132545
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: BLUEBELL MANOR
FACILITY NUMBER: 496804239
VISIT DATE: 01/29/2025
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
Per investigation, there is sufficient information obtained to support a violation had occurred. Per LPA’s investigation, review of records, including interviews with staff, and interviews with other related parties, the “staff does not ensure resident is provided a shower mat” is Substantiated.

The following deficiencies will be cited:

Maintenance and Operation 87303(e)(5)(A)- Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors, see LIC9099D.

87468.1(a)(2) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment, see LIC9099D.



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.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with the Administrator/Licensee..
Appeal Rights Provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20241108132545
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: BLUEBELL MANOR
FACILITY NUMBER: 496804239
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2025
Section Cited
CCR
87303(e)(5)(A
1
2
3
4
5
6
7
: Maintenance and Operation 87303(e)(5)(A)-Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement was not met as evidenced by: LPA's investigation, interviews with staff, and other related parties. Bath mats had been removed for an unknown time frame, staff were directed to use towels on the shower floor for resident showers. This is a risk to residents personal rights and to health & safety of residents in care.
1
2
3
4
5
6
7
POC CLEARED BY ADMINISTRATOR/LICENSEE PUTTING BATH MATS IN ALL BATHROOM SHOWER STALLS/TUBS. LICENSEE STATED THEIR UNDERSTANDING OF THE REGULATION. POC CLEARED 2/3/2025
Type B
02/10/2025
Section Cited
CCR
87468.1(a)(2)
1
2
3
4
5
6
7
87468.1(a)(2) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment, This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee to ensure all staff obtain personal rights/residents rights training. Submit proof of training by 2/1/25, include trainers name, date/time spent, topics covered.
POC due by 2/1/25.
8
9
10
11
12
13
14
LPA's investigation, interviews with staff, and other related parties. Bath mats had been removed for an unknown time frame, staff were directed to use towels on the shower floor for resident showers. This is a risk to residents personal rights and to health & safety of residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/08/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241108132545

FACILITY NAME:BLUEBELL MANORFACILITY NUMBER:
496804239
ADMINISTRATOR:SOLOMON BANAFACILITY TYPE:
740
ADDRESS:1997 BLUEBELL DRIVETELEPHONE:
(707) 800-2522
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 5DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bana Solomom-AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have adequate staffing to meet resident's needs
Staff force residents to shower
Staff do not ensure residents are provided a comfortable temperature
Staff falsify resident's records
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 1/29/2025 at approximately 10:00am, and met with Bana Solomon, Administrator/Licensee.

Reporting party alleges that “facility does not have adequate staffing to meet resident's needs, staff force residents to shower, staff do not ensure residents are provided a comfortable temperature, and staff falsify resident's records”. LPA reviewed resident files, staff files, and conducted interviews with staff (S1, S2, S3) and other related parties. LPA toured the facility with staff.

Per investigation, review of records, interviews with the staff and other related parties, the investigation revealed that residents were comfortable with the temperature in the facility. per staff interview, S2, stated they put the heater up and down as needed for the residents, residents will tell you if their hot and/or cold and want the heat higher or turned down.

Continued on LIC9099C..

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20241108132545
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: BLUEBELL MANOR
FACILITY NUMBER: 496804239
VISIT DATE: 01/29/2025
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
Interviews with staff, and other parties found no information of residents being forced to shower. No information obtained of residents needs not being met by facility staff. In review of records, and interviews conducted, there was no information obtained regarding records having been falsified. Per investigation, there was not sufficient information obtained to support violations had occurred.

Based on the LPA’s investigation, observations, interviews with staff and other related parties, the investigation, the allegations of “facility does not have adequate staffing to meet resident's needs, staff force residents to shower, staff do not ensure residents are provided a comfortable temperature, and staff falsify resident's records” are 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.
Exit interview was conducted with the Administrator Bana Solomon.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5