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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804162
Report Date: 09/14/2026
Date Signed: 09/14/2026 02:18:19 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
06/16/2026 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20260616141002
FACILITY NAME:PACIFIC GARDENS ON HAWKESBURYFACILITY NUMBER:
486804162
ADMINISTRATOR:MARY GRACE DEFEOFACILITY TYPE:
740
ADDRESS:120 HAWKESBURY WAYTELEPHONE:
(760) 296-7562
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 6DATE:
09/14/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mary Grace Defeo, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident care needs are not being met
INVESTIGATION FINDINGS:
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On 09/14/2026, at approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct further investigation and deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20260616141002, which was received by Community Care Licensing (CCL) on 06/16/2026. Reporting Party (RP) claims resident care needs are not being met. LPA met with Mary Grace Defeo, Administrator.

On 06/24/2026, LPA conducted a 10-day complaint investigation. During the visit, LPA obtained documents, made observations, and conducted interviews. The complaint identified concerns regarding the quality and quantity of food provided to Resident 1 (R1) and does not identify any other specific manner in which R1's care needs were allegedly not met.

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

DATE: 09/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026
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 2
Control Number 21-AS-20260616141002
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: PACIFIC GARDENS ON HAWKESBURY
FACILITY NUMBER: 486804162
VISIT DATE: 09/14/2026
NARRATIVE
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Continued from LIC9099...
During an interview, Administrator stated that R1 moved into the facility on 06/03/2026 at approximately 3:00 PM and remained at the facility for less than 24 hours before calling 911 at approximately 8:30 AM on 06/04/2026 and requesting transport to the emergency room (ER) for hemorrhoid pain. Administrator stated that although R1 was receiving hospice services, R1 did not want to wait to be seen by their hospice nurse.

Administrator stated that R1 requested a peanut butter and jelly sandwich and a glass of juice which Administrator states was provided. Administrator further stated that R1 received a dose of prescribed pain medication around 4:00 PM. At approximately 6:00 PM, a caregiver offered R1 dinner consisting of a cheeseburger, salad, soup, and a glass of juice. According to Administrator, R1 consumed approximately 50% of the meal, and care staff reported that R1 stated they did not have an appetite. The following morning, at approximately 7:00 AM, R1 was provided breakfast consisting of oatmeal, eggs, sausage, and orange juice. Care staff again reported that R1 ate only a small amount of the meal.

On 06/24/2026, Interviews conducted with Resident 2 (R2) and Resident 3 (R3) revealed that the food provided in the facility is of sufficient quality and quantity.

During today's inspection, LPA conducted a walk-through of the facility, completed interviews, and made observations. LPA observed that the facility maintained the required two-day supply of perishable and seven-day supply of nonperishable food. LPA observed fresh fruit, vegetables, protein, dairy products, and snacks available at the facility. LPA also observed staff preparing a hot meal for lunch consisting of ground beef, vegetables, and rice.

LPA interviewed a representative from the hospice agency, who confirmed that the only complaint reported to the agency by R1 involved the food provided at the facility. The hospice representative stated that the agency investigated R1’s concern and determined that the food provided at the facility was sufficient. Information obtained during the investigation regarding whether R1’s care needs were adequately met was conflicting.

Based on interviews conducted, observations made, and records obtained, the listed allegation is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2