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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 030317773
Report Date: 04/05/2022
Date Signed: 04/05/2022 03:35:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2022 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20220103112014
FACILITY NAME:AMADOR RESIDENTIAL CARE FACILITYFACILITY NUMBER:
030317773
ADMINISTRATOR:JULIE KRAMERFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:49CENSUS: 23DATE:
04/05/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Julie KramerTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Residents are not bathed
Residents are not changed timely
Staff left resident in soiled clothing for extended period of time
Basic laundry services are not being provided
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey-Canady arrived to the facility unannounced to deliver complaint investigation findings. Administrator Julie Kramer authorized facility staff to sign the final report.

The department has determined the following as it relates to the allegations: Residents are not bathed, Residents are not changed timely, Staff left resident in soiled clothing for extended period of time, Basic laundry services are not being provided

The investigation consisted of interviews with eight staff members (S1 - S8), two outside agencies (OA1 - OA2), and four residents (R1 - R4). According to S1, S1 observed residents not being cared for properly and informed management about observations. S1 stated there a handful of staff that want to come forward but can't due to the dynamics of upper management.
Continues on LIC 9099-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
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 27-AS-20220103112014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773
VISIT DATE: 04/05/2022
NARRATIVE
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According to S2 and S3, they are unaware of any concerns relating to personal rights of the residents. According to S4, S4 reported that AM staff sit in the break room all shift and residents are left in soiled diapers. According to S5 and S6, the facility has ADL logs and a care system in place in order to ensure proper care is provided to all the residents. S6 stated S6 was surprised by the complaint because S6 felt the staff go the extra mile to care for residents.

According to interviews with OA1 and OA2, OA1 and OA2 have visited the facility for a few years and have observed the interactions with staff and residents. OA1 reported no issues to be observed with OA1's client, which has resided at the facility for over two years. OA2 has a close relationship with a resident and has heard great things from the the resident. OA2 had a family member previously live at Amador Residential Care Facility and stated the staff were very kind and attentive to the family member.

According to interviews with residents, residents are assisted and did not mention anything regarding staff not being able to assess with ADLs.

According to records review of six resident files, LPA observed residents to have updated documents, including Activities of Daily Living (ADL) logs, Showering Logs, and set laundry schedule. LPA observed the ADL log to be signed every shift. Residents are assisted every 3 hours to be assisted with toileting and assisted every other day for showered. If any resident refuses and/or is unable to complete an ADL task for the hour, it is electronically logged by the staff.

LPA observed the facility on 01/04/22 and 03/22/22. LPA observed laundry service being provided throughout the shift during each visit. Staff reported that the facility has a set laundry schedule for the day. However, if any resident has soiled laundry, the facility will wash the items on the same day.

Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED. Due to the above noted information, 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, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.
Page 2 of 2
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/03/2022 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20220103112014

FACILITY NAME:AMADOR RESIDENTIAL CARE FACILITYFACILITY NUMBER:
030317773
ADMINISTRATOR:JULIE KRAMERFACILITY TYPE:
740
ADDRESS:155 PLACER DRIVETELEPHONE:
(209) 223-4444
CITY:JACKSONSTATE: CAZIP CODE:
95642
CAPACITY:49CENSUS: DATE:
04/05/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:TIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Food is not handled or cooked properly
Food is being served cold
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio and LPA Jamie Ivey-Canady arrived to the facility unannounced to deliver complaint investigation findings. Administrator Julie Kramer authorized facility staff to sign the final report.

The department has determined the following as it relates to the allegations: Food is not handled or cooked properly and Food is being served cold

The facility was observed on two separate occasions, 01/04/22 and 03/22/22. On 01/04/2022, soup was observed to be steaming, residents did not have negative comments to say about food, and staff used meat thermometers to determine meat temperature. On 03/22/22, residents were observed to be enjoying their meal and did not comment negatively regarding the meal.

Continues on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20220103112014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773
VISIT DATE: 04/05/2022
NARRATIVE
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...Continues from LIC 9099-A

LPA observed the kitchen. The oven, which is required to cook meats, vegetables, and baked goods, had knobs that were worn down to the point where numbers were missing. LPA requested staff to move heating trays from the heating table. LPA observed rust throughout the entire unit. LPA observed the warming plate heaters to be non-operational, which according to staff have not worked for a long time.

According to S1, food is served cold and frozen and there are times where it takes a long time for meals to be served. S1 observed a time where fries were served frozen. S2 stated the food is not bad and recalled of one resident who has asked to warm their food up due to it not being at their preferred temperature. S3 stated there is one resident who has constantly stated food needs to be warmed up. S4 stated food is not prepared fresh. S4 stated most of the residents do not have the cognitive capacity to inform staff that their food is cold or not cooked. S5 stated that when the facility had a COVID outbreak, the food was getting to the residents cold because they were not able to use the warming trays. The food would be warm once it left the kitchen; however, it would get cold once it got to the end of the hall. S7 and S8 informed LPA that the knob for the kitchen oven does not have numbers to indicate cooking temperatures and they have to guess when they cook. S7 and S8 reported they use heat thermometers to check if meat is cooked. For other items, they judge the cooking times based on experience and observation.

Based on observations and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted, and a copy of the report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20220103112014
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AMADOR RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 030317773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2022
Section Cited
CCR
87555(b)(29)
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87555 General Food Service Requirements(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair.. This requirement was not met as evidenced by:
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Licensee stated the kitchen will be cleaned entirely and LPA will be kept updated with progress on obtaining new or updated kitchen applicances by POC due date.
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Based on interviews and observations, the facility did not ensure ktichen cookware items were in good repair, which poses a potential health and safety risk to persons in care.
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Type B
05/05/2022
Section Cited
CCR
87555(b)(9)
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87555 General Food Service Requirements
(b) The following food service requirements shall apply:(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by:
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Licensee stated all kitchen staff will receive in-service training regarding General Food Service Requirements and Food Handling. Licensee to send LPA Valerio in-service training sign in sheet by POC due date.
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Based on interviews and observations, the facility did not ensure proper procedures were in place to ensure food was measured at a hot and warm temperature at all times due to equipment not working, which poses a potential health and safety 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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5