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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804239
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:11:01 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
11/12/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241112162814
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: DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bana Solomon-AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff does not follow physician's orders
Staff are over medicating the resident
INVESTIGATION FINDINGS:
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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 “staff does not follow physician's orders, and staff are over medicating the resident”. LPA reviewed resident files, staff files, and conducted interviews with staff (S1, S2, S3) and other related parties.

LPA toured the facility with staff. LPA observed all of the residents in the facility, and met with some of the residents in care.LPA interviewed staff, and other related parties.

Per investigation, review of records, interviews with the staff and other related parties, the investigation revealed that residents, R1 & R2, medications all have Dr's Orders, routine and PRN orders. Per interviews, with staff, and other related parties, medications are being provided as ordered. All medication records were found to be in order.

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: 1 of 2
Control Number 21-AS-20241112162814
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
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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 “ “staff does not follow physician's orders, and staff are over medicating the resident” 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: 2 of 2