315002812-10-5-2023-59-AS-KHOS-CWPS2P-20231017132953

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002812
Report Date: 10/05/2023
Date Signed: 10/05/2023 02:51:50 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2023 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 59-AS-20230912152259

FACILITY NAME:	BLESSED HOMECARE 2 ROSEVILLE		FACILITY NUMBER:	315002812
ADMINISTRATOR:	ARGANA, FERDINAND		FACILITY TYPE:	740
ADDRESS:	4100 SHORTHORN WAY		TELEPHONE:	(209) 834-4040
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	6	CENSUS: 6	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Susan Bustamante		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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1. Staff are restricting resident visits
2. Staff do not ensure that resident is appropriately dressed
3. Staff isolate resident in his room
4. Staff do not prevent visitors from posting resident confidential information in the facility
5. Staff mask medication in resident's food
6. Staff did not provide a bed that met the resident's needs
7. Furniture in the resident's room violates the facility fire clearance
8. Staff prohibit resident from eating without assistance from staff

INVESTIGATION FINDINGS:

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LPA Hiratsuka, conducted this unannounced complaint visit to deliver the results into the allegations above.

LPA reviewed resident files and conducted interviews with responsible party, Licensee, one staff, and two witnesses.

1. The resident has a conservator who has paperwork that states they may restrict vistations. Staff stated they do not restrict visitors.

2. LPA interviewed resident in question. Resident stated they do not want to wear certain clothing items at all times. LPA interviewed responsible party and two witnesses and all stated the resident does not want to wear certain clothing items and they have the right to refuse and to wear what they want.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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-20230912152259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE	FACILITY NUMBER: 315002812
	VISIT DATE: 10/05/2023

NARRATIVE

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3. LPA interviewed resident in question. Resident stated they do not want to socialize with anyone and is content in their room. LPA interviewed responsible party and the two witnesses and all stated the resident has told them the resident does not wish to visit with the other people living in the facility and is content in their room.

4. LPA interviewed the witnesses. The note was not on the door when LPA visited on 09/14/2023. LPA was informed by one witness that it did not have any confidential information. It just stated to not wake up the resident if the resident was sleeping when visitors showed up because the resident does not want to be woken up and instructions for what to do if someone insisted on visiting against the resident's wishes. Responsible party stated the resident has always slept at random times and has never liked to have their sleep interrupted for a long as they have known each other.

5. LPA reviewed medication orders and conducted interviews. There are orders to crush the medications and to put it on food. Caregiver stated the medications are put on foods the resident likes to eat to try to ensure the resident will take it, but the resident refuses to take medications a lot. LPA confirmed that with the responsible party. Resident stated they do not get tricked into taking medications. Witness stated the resident refuses to take medications at times. The responsible party told LPA the resident has take naps at random times for as long as they have known each other and the resident is not over-medicated.

6. LPA interviewed Licensee. Licensee stated when the resident was admitted to hospice the hospice agency ordered a bed that did not originally fit the resident and so the agency had to order a new one. The resident was in the original hospice bed until a new one arrived that better fit the resident. This was confirmed by the responsible party.

7. All witnesses interviewed stated nothing blocked the bed the resident is in. They stated there were two beds in the room for a short time but the second bed was pushed up against the far wall and there was a lot of space between the beds. The witnesses stated they have not seen anything blocking any exits to the outside or anything blocking beds. LPA toured the facility on 09/14/2023, and did not see any fire hazards.

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20230912152259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BLESSED HOMECARE 2 ROSEVILLE	FACILITY NUMBER: 315002812
	VISIT DATE: 10/05/2023

NARRATIVE

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8. LPA interviewed two residents and both stated they get enough to eat. One was the resident in question and that resident stated they get more than enough food when they want it. Both stated the food is good. A witness stated they ask the resident when visiting if the resident is hungry and if the resident states they are the caregivers bring a meal to the resident and assist if need. The responsible party stated the resident gets enough to eat when the resident wants it.

Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

no deficiencies cited

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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