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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700133
Report Date: 12/20/2022
Date Signed: 12/20/2022 10:09:55 AM

Substantiated


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
12/13/2022 and conducted by Evaluator Christina Valerio
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221213145103
FACILITY NAME:SILVER PINES CARE HOME I LLCFACILITY NUMBER:
342700133
ADMINISTRATOR:LOESCH, DEBBIEFACILITY TYPE:
740
ADDRESS:8625 HUME COURTTELEPHONE:
(916) 686-1936
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
12/20/2022
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Debbie LoeschTIME COMPLETED:
10:10 AM
ALLEGATION(S):
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Facility staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannouced to conduct a 10-Day Complaint Investigation and deliver complaint findings. LPA met with Administrator Debbie Loesch, and explained the purpose of the visit.

Administrator Debbie Loesch self reported an incident to the regional office on 12/12/2022. On 12/12/22, a staff member, Staff 1 (S1), made physical contact with a resident, Resident 1 (R1). S1 was assisting R1 in the shower. R1 bit down on S1's upper arm. S1 reacted by slapping R1 in the head with hand. The assistant administrator immediately removed the S1 from the shower was suspended. Police and family were contacted. R1 has a dx of dementia and could not remember what happened when asked by police and/or staff. Administrator gave voicemail of S1 admitting to the incident, a written report from staff, and case number for Elk Grove Police Department.
Per California Code of Regulations, Title 22, deficiences are being cited on LIC 9099-D. Failure to correct deficiences may result in civil penalities. An exit interview was held, and a copy of the report was provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
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-20221213145103
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: SILVER PINES CARE HOME I LLC
FACILITY NUMBER: 342700133
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/21/2022
Section Cited
CCR
97468.1(a)(3)
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87468.1 Personal Rights of Residents... (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... This requirement was not met as evidenced by:
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Licensee stated the staff member was immediately removed from the facility by management staff. Licensee gave LPA internal documents of investigation. Licensee held an in-service training with all staff on Elder Abuse. LPA to receive the in-service sign in sheet by POC due date.
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Based on records review and interviews, the licensee did not ensure 1 out of 6 residents were free from physical abuse by staff 1. This poses an immediate health and safety risk to residents in care.
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This report was amended to change the deficiency type from a Type A to Type B.
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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: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC9099 (FAS) - (06/04)
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