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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097000124
Report Date: 10/03/2022
Date Signed: 10/03/2022 01:06:16 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2021 and conducted by Evaluator Melissa Parks
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210624152547
FACILITY NAME:APPLE COUNTRY CARE HOMEFACILITY NUMBER:
097000124
ADMINISTRATOR:FOSS, LAURAFACILITY TYPE:
740
ADDRESS:4330 HARNESS TRACTTELEPHONE:
(530) 644-3026
CITY:CAMINOSTATE: CAZIP CODE:
95709
CAPACITY:7CENSUS: 4DATE:
10/03/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Laura FossTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident sustained a fractured arm while in care
Facility staff did not seek medical attention for resident
Facility did not allow resident's medical provider to visit the resident
Resident was inappropriately restrained while in care
Facility staff did not follow resident's hospice plan
Facility staff yelled at residents
Facility staff placed residents medication in food
INVESTIGATION FINDINGS:
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LPA Parks arrived on Monday October 3, 2022 to conclude a complaint investigation regarding the following allegations: resident sustained a fractured arm while in care, facility staff did not seek medical attention for resident, facility did not allow resident's medical provider to visit the resident, facility staff did not follow resident's hospice plan, and Facility staff placed resident’s medication in food, resident was inappropriately restrained whie in care and facility staff yelled at residents .

Prior to the visit, LPA completed the required COVID-19 testing protocols and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA Parks spoke with Licensee Mary Heider on the phone and expained the findings. LPA discussed the findings with Laura Foss at the facility. Throughout the course of the investigation, LPA interviewed
Unfounded
Estimated Days of Completion: 0
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
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 2
Control Number 25-AS-20210624152547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: APPLE COUNTRY CARE HOME
FACILITY NUMBER: 097000124
VISIT DATE: 10/03/2022
NARRATIVE
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staff. Additionally, LPA reviewed R1’s admission agreement, progress notes, hospice medication list, physicians report and PT notes. While R1 did sustain a fractured arm while at the facility, this was not due to neglect or lack of staffing. R1 was an active resident who was able to ambulate from the recliner. LPA reviewed PT orders and progress notes. Hospice care plan was followed by the facility. Staff interviewed acknowledge that they follow the facility’s policy regarding falls. Additionally, morphine is given per the instructions on the medication order. All staff interviewed stated that they have never witnessed staff yelling or raising their voices.

Based on LPAs interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report was left at the facility.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Melissa Parks
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2