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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002913
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:21:58 PM

Substantiated


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
09/17/2024 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 59-AS-20240917090004
FACILITY NAME:A LOVING ARM HOME LLCFACILITY NUMBER:
315002913
ADMINISTRATOR:INVIERNO, VERONICA R.FACILITY TYPE:
740
ADDRESS:409 GLIMMER PLACETELEPHONE:
(916) 872-0384
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
09/19/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Veronica R. Invierno, AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff handled resident in a rough manner.
Staff spoke to resident in an inappropriate manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open complaint investigation. LPA met with Administrator Veronica Invierno during today's investigation.
During today's investigation LPA interviewed staff and residents and reviewed resident documentation. Through interviews with resident and staff it was found that on Monday September 16th, Caregiver (C1) became upset with the administrator at approximately 9 am concerning payroll disagreements. Administrator confronted C1 on how C1 speaks to other residents and staff. Administrator took C1 to resident (R1) room to ask for R1's opinion. During that conversation, C1 began to yell at R1 and pushed R1 against the wall and took R1's face into her hands and shook R1's face.
Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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-20240917090004
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: A LOVING ARM HOME LLC
FACILITY NUMBER: 315002913
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2024
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
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Administrator has terminated employment of caregiver. Administrator to obtain training on resident personal rights from an outside agency.
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This requirement is not met as evidenced by: Based on interviews, the licensee did not protect resident rights which poses an immediate health and safety risk to residents in care.
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Copy of training that administrator has signed up for to be sent into CCL by 9/20/24.
Type A
09/20/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Administrator has terminated employment of caregiver. Administrator to obtain training on resident personal rights from an outside agency.
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This requirement is not met as evidenced by: Based on interviews, the licensee did not protect resident rights which poses an immediate health and safety risk to residents in care.
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Copy of training that administrator has signed up for to be sent into CCL by 9/20/24.
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: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240917090004
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: A LOVING ARM HOME LLC
FACILITY NUMBER: 315002913
VISIT DATE: 09/19/2024
NARRATIVE
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Administrator intervened and C1 was still yelling but retreated to their living area. R1 called the police after the incident.
Due to the information gathered through interviews LPA finds allegation, "Staff handled resident in a rough manner" and "Staff spoke to resident in an inappropriate manner" to be substantiated.
As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies cited on 9099-D.

Copy of report provided to the facility.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Mirlohi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3