Complaint Investigation Report

The following was reported to Community Care Licensing (CCL), Santa Rosa Regional Office:

Client (C1) was admitted to the hospital on 03/03/2022 due to stomach issues. On 03/15/2022 a Meadowlark Manor staff member (S1) arrived to pick up C1, was overheard and observed speaking to a male (believed to be another staff member) on the phone. It was alleged S1 made a comment that they miss the smell of C1's genitals to a staff member over the phone. S1 used a nick-name for C1's genitals. Staff interviews indicated S1 was speaking to their marital partner over the phone, not another staff member when S1 made the comment about C1.

Staff interviews conducted and written statements received revealed S1 & S2 have made comments about missing the smell of C1's genitals or the way C1's genitals smell, on multiple occasions. Staff interviews indicated S1 & S2 were "joking around". Additionally, Meadowlark Manor did not report this incident to CCL initially, LPA received a copy of the report on 03/21/2022 after opening the complaint and questioning if the facility has reported. The facility reported to North Bay Regional Center with an incident report. Administrator stated S1 resigned on 03/29/2022.

Based on observations, records reviewed, and interviews conducted, the licensee did not ensure clients personal rights to dignity and respect between staff and clients due to Staff member who violated resident's personal rights . The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies cited (see LIC9099-D page) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Marie Fernandez, Administrator whose signature below confirms receipt of report.