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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097000124
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:56:19 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
03/14/2023 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 59-AS-20230314115308
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: 5DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:House Manager Laura FossTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff force fed resident.
Staff yelled at resident.
Resident was left soiled for a long period of time.
Resident not allowed access to a telephone.
Facility did not notice a change in resident's condition.
Resident restrained to a wheelchair.
INVESTIGATION FINDINGS:
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On 5/17/23, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with House Manager Laura Foss.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 59-AS-20230314115308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: APPLE COUNTRY CARE HOME
FACILITY NUMBER: 097000124
VISIT DATE: 05/17/2023
NARRATIVE
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Staff force fed resident.
Department conducted interviews with staff and residents, records were reviewed, and facility observation was done to investigate this complaint allegation. Interviews indicated that facility staff were not forcing residents during their meals and providing assistance only to those residents who are unable to feed themselves. Staff interviews indicated that if residents refuse to eat, facility was offering meal replacement drinks or snacks to the residents. Based on this information, this allegation was found to be unfounded.

Staff yelled at resident.
Department conducted interviews with staff and residents, records were reviewed, and facility observation was done to investigate this complaint allegation. From the interviews, it has been concluded that facility staff were not yelling at residents. Residents’ interviews conducted on 3/20/23 and 5/17/23 indicated that staff were talking loud to those residents who were hard of hearing but not yelling at residents. Based on this information, this allegation was found to be unfounded.

Resident was left soiled for a long period of time.
Department conducted interviews with staff and residents, records were reviewed, and facility observation was done to investigate this complaint allegation. Staff and residents interviewed on 3/20/23 and 5/17/23 indicated that staff were providing incontinence care to residents every 2 hours or as needed per their needs and service plan. Residents interviewed indicated that staff were not leaving them soiled for long times and staff provide assistance for their incontinence care needs as needed. Based on this information, this allegation was found to be unfounded.

Resident not allowed access to a telephone.
Department conducted interviews with staff and residents and facility observations were done to investigate this complaint allegation. Based on interviews conducted it has been concluded that residents have access to the working phone, and they can speak to their family whenever they want to. During department visits on 3/20/23 and 5/17/23 it has been observed that facility has working phone in the common area accessible to all residents for use. Based on this information, this allegation was found to be unfounded.

Continued on 9099-C ...
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20230314115308
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: APPLE COUNTRY CARE HOME
FACILITY NUMBER: 097000124
VISIT DATE: 05/17/2023
NARRATIVE
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Facility did not notice a change in resident's condition.
Department conducted interviews with staff and residents, records were reviewed, and facility observation were done to investigate this complaint allegation. Based on interviews and records reviewed it has been concluded that facility staff document changes of condition for residents and notify their physician, family member and two other reporting agencies in a timely manner. Facility staff have access to all resident files and staff can call 9-1-1 for any emergency for residents as needed. Based on this information, this allegation was found to be unfounded.

Resident restrained to a wheelchair.
Department conducted interviews with staff and residents, records were reviewed, and facility observations were done to investigate this complaint allegation. Based on staff and residents’ interviews conducted on 3/20/23 and 5/17/23 it has been concluded that facility was not using any restrained for any residents. During the department visits on 3/20/23 and 5/17/23 it has been observed that all residents were attending activities, watching tv in the common area and resting in their rooms without any restraints. Based on this information, this allegation was found to be unfounded.

Exit interview was conducted with House Manager and a copy of this report was provided to the facility. The signature of the House Manager on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3