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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700018
Report Date: 07/23/2021
Date Signed: 07/23/2021 05:12:44 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
06/23/2021 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20210623113350
FACILITY NAME:GROVE HOME CAREFACILITY NUMBER:
342700018
ADMINISTRATOR:BOBOC, LUCIAFACILITY TYPE:
740
ADDRESS:8410 TERRACOTTA CIRCLETELEPHONE:
(916) 225-6405
CITY:SACRAMENTOSTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 5DATE:
07/23/2021
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Lucia BobocTIME COMPLETED:
05:12 PM
ALLEGATION(S):
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Licensee physically abused resident resulting in fracture
Staff did not give medication as prescribed
INVESTIGATION FINDINGS:
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On 7-23-21 at 4:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the the allegations listed above. Throughout this investigation, facility records, hospital records, and medication records were reviewed. Additionally, interviews were conducted with Residents2 (R2), and R5, as well as Staff1 (S1), and Administrator.

Allegation - Licensee physically abused resident resulting in fracture - LPA reviewed facility and hospital records. Based on record reviews, it was determined that a resident was sent to the hospital on 6/24/21 after alleging that she was kicked in the ankle by the Administrator causing a fracture. Upon record review based on on nursing report from hospital received by LPA on 6-29-21, it was revealed that a resident has an external fixator due to a previous fracture. Furthermore, it was revealed that previous fracture was not related to any type of abuse. Moreover, it was revealed that multiple x-rays were taken and did not indicate new fractures, and the previous fracture was stable and healing with no new acute fractures. (Cont. on 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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 2
Control Number 27-AS-20210623113350
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: 07/23/2021
NARRATIVE
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Further review of medical records reveal that a registered nurse described that it "would have been difficult to kick the paitient's ankle through the hardware." LPA interviewed R2 and R5 on 7-8-21 at 1:05pm. Based on interview, it was revealed that there have been no observations of physical abuse towards any residents in care past or present.. LPA did not observe R2, R3, R4, or R5 to have any notable bruising, tearfulness, sad expressions, or facial grimaces during interviews. LPA interviewed Staff1 (S1) on 7-8-21 at 1:30pm. Based on interview it was revealed that there have been no observations of physical abuse towards any residents past or present. LPA observed environment to be clean, sanitary, and quiet during visit. Based on record reviews, observation, and interviews, it is determined that the preponderance of evidence standard has not been met, there this allegation is UNSUBSTANTIATED

Allegation - Staff did not give medication as prescribed - LPA reviewed Physician Reports (602) and medication orders for resident. LPA also interviewed Administrator. Based on record review, it was revealed that there are no physician orders for an antibiotic a resident alleges was not given as prescribed in the resident files. Review of hospital and skilled nursing records reveal that there were no previous physician orders for an antibiotic prior to resident's arrival at facility for the resident. Based on interview with Administrator, it was revealed that the antibiotic was present but could not be given due to no Physician orders present. Based on record reviews and interviews, it is determined that the preponderance of evidence standard has not been met, therefore, this allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2