<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 097000124
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:54:48 AM

Unsubstantiated


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
01/18/2023 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20230118171400
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):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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**
Unsubstantiated
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 25-AS-20230118171400
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Resident sustained unexplained injuries.

During this investigation, staff and residents were interviewed and facility and medical records were reviewed. S2 acknowledged the incident in question and stated that S1 reported an incident on 01/12/2023 which resulting in R1 falling and sustaining a fracture. Specifically, S1 said R1 fell while in the bathroom during a diaper change. Present for the incident was S1. Based on interview with S1, R1 did not present any significant indication of immediate distress after their fall. S1 clarified that the incident was a fall that S1 witnessed versus an unwitnessed fall from R1’s bed. S1 was changing R1’s adult diaper when R1 abruptly tried to "bolt" away. In the process. S1 held onto R1’s adult diaper and pants to prevent R1 from falling or injuring themself. As a result, R1 fell backwards and onto S1. S1 was questioned as to why S1 did not call 911. S1 indicated that R1 did not appear in any distress, nor complained of pain. After the incident, S1 immediately reported the fall to facility management. Interviews indicated that S1 actively checked on R1 throughout the night to assess for a change in condition. S1 indicated that after R1 reported being in pain on 1/13/2023, R1 was promptly taken to the hospital. Based on the information and evidence, it was determined there is insufficient evidence to substantiate the allegation, therefore the allegation is unsubstantiated. This agency has investigated the above listed allegation(s). Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, we have found the allegation(s) to be UNSUBSTANTIATED.

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: 2 of 3
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
01/18/2023 and conducted by Evaluator Lavinia Muscan
COMPLAINT CONTROL NUMBER: 25-AS-20230118171400

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):
1
2
3
4
5
6
7
8
9
Facility failed to meet reporting requirements.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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.

Allegation: Facility failed to meet reporting requirements.

Based on interviews conducted and file reviewed, facility notified the Department of Incident, which meets Title 22 reporting requirements. Therefore, the allegation is unfounded meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

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.
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: 3 of 3