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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 286804030
Report Date: 05/28/2026
Date Signed: 05/28/2026 08:01:18 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
12/12/2025 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20251212082305
FACILITY NAME:BERKSHIRE, THEFACILITY NUMBER:
286804030
ADMINISTRATOR:DHAWAN, BABITAFACILITY TYPE:
740
ADDRESS:2300 BROWN STREETTELEPHONE:
(510) 996-8520
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY:72CENSUS: 24DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Manuel Baldeo, Designated Responsible PartyTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained severe injuries.
Staff retained a resident with a prohibited health condition.
INVESTIGATION FINDINGS:
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On 05/28/2026, at approximately 10:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20251212082305, which was received by Community Care Licensing (CCL) on 12/12/2025. Reporting Party alleges due to staff neglect, resident sustained severe injuries and staff retained a resident with a prohibited health condition. LPA met with Manuel Baldeo, Designated Responsible Party (DRP).

On 12/8/2025, Resident 1 (R1) presented to the hospital with an unstageable pressure wound to their
coccyx area, stage II pressure wound to their left hip, and fluid-filled blisters on both heels.
R1’s recurrent coccyx injury was present but almost fully healed upon their admission to
the facility (9/24/2025). No other wounds were present at the time.

Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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 3
Control Number 21-AS-20251212082305
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: BERKSHIRE, THE
FACILITY NUMBER: 286804030
VISIT DATE: 05/28/2026
NARRATIVE
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Continued from LIC9099...

Staff reported they repositioned R1 every two hours and home health services were requested but not approved until 12/4/2025. Certified Wound and Ostomy Nurse RN, W1, reported it likely took “Some time” for the wounds to develop. W1 believed staff should have sought medical attention sooner based on the smell and appearance alone. The Berkshire Director of Operations, Lia Miller reported that the severity of the wounds were not properly reported to her. Lia further stated, “People (care staff) were seeing and not saying…” Concerns with staffing deficiencies were also shared by staff and residents’ family members. Conflicting staff reports regarding the severity of the wounds, concerns related to staffing deficiencies,
and the emergence of severe additional pressure wounds support the allegations (see LIC9099D). An immediate civil penalty in the amount of $500 if being issued during today's visit as the result of neglect/lack of care and supervision due to resident R1 sustaining severe injuries (see LIC421IM).

After sustaining severe pressure injuries at The Berkshire, R1 subsequently died on 12/31/2025. According to R1’s death certificate, a significant condition which contributed to their death was acute sepsis syndrome. Prior to R1’s passing, W1 reported that it was clear to them that R1’s injuries and condition could hasten R1’s end of life outcome.

Based on interviews conducted and records obtained, the allegations that due to staff neglect, resident sustained severe injuries and staff retained a resident with a prohibited health condition are SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from Title 22 Regulations, Division 6, (see LIC9099D). DRP was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49(f).

Exit interview conducted. Copy of report discussed and provided to DRP, whose signature on form confirms receipt of documents. Appeal rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20251212082305
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: BERKSHIRE, THE
FACILITY NUMBER: 286804030
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2026
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care 87465(a)(1) The licensee shall arrange, or assist in arranging, for medical...care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by: Based on facility not ensuring R1 was sent out for timely medical evaluation of observed
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Licensee to submit self-certification that regulations 87465 Incidental Medical and Dental Care and 87466 Observation of a Resident have been reviewed with facility staff and are understood to CCL by Plan of Correction (POC) due date 05/29/2026.
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changes to R1's condition, resulting in the emergence of severe additional pressure wounds which ultimately contributed to R1's acute sepsis syndrome and death, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
05/29/2026
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions: (a) Persons who require health services... specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3...pressure injuries.
This requirement was not met as evidenced by:
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Licensee to submit a written statement that they understand the regulation 87615(a)(1) and shall be in future compliance to CCL by Plan of Correction (POC) due date 05/29/2026.
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Based on record review and interviews conducted, staff did not ensure the above regulation as evidenced by R1 sustaining an unstagable pressure injury while in care which poses an immediate health, safety or personal rights risk to persons in care.
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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: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3