342700018-7-8-2021-27-AS-KHOS-C4WJSL-20210714071830

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700018
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:40:51 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/09/2021 and conducted by Evaluator Michael Bilger

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210609125402

FACILITY NAME:	GROVE HOME CARE		FACILITY NUMBER:	342700018
ADMINISTRATOR:	BOBOC, LUCIA		FACILITY TYPE:	740
ADDRESS:	8410 TERRACOTTA CIRCLE		TELEPHONE:	(916) 225-6405
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	07/08/2021
		UNANNOUNCED	TIME BEGAN:	10:49 AM
MET WITH:	Lucia Boboc		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Resident feels retaliation from Licensee
Staff failed to properly prepare food
Staff verbally abusive towards resident
Resident care needs not being met

INVESTIGATION FINDINGS:

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On 7/8/21 at 10:49am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a complaint investigation for the allegations listed above. LPA met with Administrator Lucia Boboc and explained the purpose of the visit. Throughout this investigation, interviews with Administrator, Staff1 (S1), and Residents2 (R2) to R5 were conducted. Resident records were also reviewed including physician reports (602 forms), staffing roster, resident roster, and current menu. LPA also performed overall observation of facility including resident rooms, dining room, kitchen, and outdoor area.

Allegation: Resident feels retaliation from Licensee - LPA interviewed R2, R3, R4, and R5 on 7-8-21 between 11:30am and 12:00pm. R2 and R5 both stated that they feel safe within their environment and do not feel any sense of danger or retaliation from staff members. LPA observed R3 and R4 as they were unable to express answers. LPA also reviewed resident records. R2 and R5 also stated through interviews that all needs are being met. R2 and R5 also stated through interview that there have been no witnessed retaliation towards other residents in care. (cont. on 9099c)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20210609125402

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: GROVE HOME CARE	FACILITY NUMBER: 342700018
	VISIT DATE: 07/08/2021

NARRATIVE

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LPA interviewed S1 on 7-8-21 at 12:15pm, who stated no witnessed retaliation from other staff members. Based on interviews, observation, and record reviews, it is determined that the preponderance of evidence standard has not been met, therefore this allegation is UNSUBSTANTIATED.

Allegation - Staff failed to properly prepare food. - LPA reviewed facility menu which contained appropriate food amounts and nutritional guidelines. Interviews with R2 and R5 revealed that special diets are accommodated and prepared correctly for them. Interview with Resident1 (R1) stated a frozen burrito was served to her. Based on review of menu, there was not a frozen burrito present. Additionally, based on interview with R2 and R5, only a frozen burrito was served to R5 per request only. LPA observed meal served to R2 which contained items from menu and meeting nutritional guidelines. Based on record reviews, observation and interviews it is determined that the preponderance of evidence standard has not been met, therefore, this allegation is UNSUBSTANTIATED.

Allegation - Staff verbally abusive towards resident - LPA interviewed R2 and R5 on 7-8-21 at 11:40am. Based on interviews, it was revealed that there have been no instances of verbal aggression or abuse received or witnessed within the facility towards other residents current or in the past. LPA observed no verbal aggression or abuse during visit. Interview with S1 revealed no observations of verbal aggression or abuse towards other residents current or past. LPA's also observed a calm, quiet, and clean environment. Based on interviews and observation, it is determined that the preponderance of evidence standard has not been met, therefore this allegation is UNSUBSTANTIATED

Allegation - Resident care needs not being met - LPA reviewed physician reports (602 form) for R1-R5. LPA interviewed R2 and R5 on 7-8-21 at 11:50am. Based on interviews, it was revealed that all care needs are met including medications, food preparation, and Activities of daily living (ADLs). LPA observed all resident rooms and found them clean and sanitary. LPA also observed the outside of facility to be free of clutter and obstructions to entry and exit ways. LPA's interview with Administrator revealed that Administrator was able to state the policy of picking up medication as necessary to ensure resident needs. Interviews with R2 and R5 revealed medications are given timely and appropriately. LPA did not observe any residents eating in unsanitary conditions during facility tour, and observed appropriate food portions given. Based on record reviews, interviews, and observation, it is determined that the preponderance of evidence standard has not been met, therefore, this allegation is UNSUBSTANTIATED. An exit interview was conducted with Lucia Boboc and a copy of this report was left with Lucia.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021

LIC9099 (FAS) - (06/04)

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