<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700299
Report Date: 05/04/2021
Date Signed: 05/04/2021 05:04:35 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2020 and conducted by Evaluator Konnor Leitzell
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201223153850
FACILITY NAME:HAPPY MEMORIES SENIOR CAREFACILITY NUMBER:
342700299
ADMINISTRATOR:CHIS, CARMENFACILITY TYPE:
740
ADDRESS:255 CIMMARON CIRCLETELEPHONE:
(707) 365-6353
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 5DATE:
05/04/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Soloman Chis (Designated Admin)TIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Reporting Requirements
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Konnor Leitzell contacted administrator to deliver the findings for the above allegation. LPA delivered findings via telephone due to COVID-19 Precautionary Measures. LPA was in contact with Solomon Chis (Designated Admin) to discuss the above allegation and go over the investigation process.

During the course of the investigation, LPA reviewed documents and conducted interviews. LPA was originally informed facility had a COVID-19 Positive resident late 12/4/2020, with Soloman calling LPA Leitzell and discussing the next steps over the phone. LPA informed Soloman that he was to submit Unusual Incident/Injury Reports (LIC624) to LPA via fax; along with contacting the Local Department of Public Health (Sac CDPH) and the Long Term Care Ombudsman (LTCO) informing them of the Positive case. Admin sent LIC 624’s to (916) 653-9335, and made contact with both Sac CDPH and LTCO later the day (12/4/2020) due to it being a Friday. CONT LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
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 4
Control Number 27-AS-20201223153850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: HAPPY MEMORIES SENIOR CARE
FACILITY NUMBER: 342700299
VISIT DATE: 05/04/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Admin found the above fax number on the CDSS.ca.gov home page, which is for CCLD’s main regional office, and not the Sacramento North Regional Office Fax number (916) 263-4744. Admin attempted to submit the LIC624’s to LPA, but did not ensure the correct fax number was being used. LPA did not receive the LIC624’s via fax, and did not follow up with facility regarding COVID-19 Positives until notified 12/23/2020 by RP. LPA received date stamped documentation of faxes sent.

Through documents reviewed and interviews conducted, it is determined the allegation of “Reporting Requirements” to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. LPA reviewed complaint with licensee, and will send a copy of report by email along with a read receipt. LPA informed admin to sign and return one copy by COB 5/5/2021.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2020 and conducted by Evaluator Konnor Leitzell
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20201223153850

FACILITY NAME:HAPPY MEMORIES SENIOR CAREFACILITY NUMBER:
342700299
ADMINISTRATOR:CHIS, CARMENFACILITY TYPE:
740
ADDRESS:255 CIMMARON CIRCLETELEPHONE:
(707) 365-6353
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:6CENSUS: 5DATE:
05/04/2021
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Soloman Chis (Designated Admin)TIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to provide a safe environment for residents.
Admin qualifications
Conduct inimical
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Konnor Leitzell contacted administrator to deliver the findings for the above allegations. LPA delivered findings via telephone due to COVID-19 Precautionary Measures. LPA was in contact with Soloman Chis (Admin) to discuss the above allegation and go over the investigation process.

During the course of the investigation, LPA reviewed documents and conducted interviews. LPA was originally informed facility had a COVID-19 Positive resident late 12/4/2020, with Soloman calling LPA Leitzell and discussing the next steps over the phone. LPA informed Soloman that he was to submit Unusual Incident/Injury Reports (LIC624) to LPA via fax; along with contacting the Local Department of Public Health (Sac CDPH) and the Long Term Care Ombudsman (LTCO) informing them of the Positive case. Admin sent LIC 624’s to (916) 653-9335, and made contact with both Sac CDPH and LTCO later the day (12/4/2020) due to it being a Friday.
CONT. LIC 9099C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20201223153850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: HAPPY MEMORIES SENIOR CARE
FACILITY NUMBER: 342700299
VISIT DATE: 05/04/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Leitzell did not receive LIC624’s due to the Fax number being for CCLD’s main regional office, and not the Sacramento North Regional Office Fax number (916) 263-4744. LPA did not follow up with facility until RP notified LPA of positives on 12/23/2020.

Per the Provider Information Notice 20-23-Adult and Senior Care (PIN 20-23-ASC), facilities are to conduct mass testing as soon as possible after one (or more) COVID-19 positive individual is identified in a facility, every 14 days until no new cases are identified in two sequential rounds of testing. Facility is also to isolate positive individuals away from negative, wear PPE while at the facility, and ensure positive staff are not working with negative residents per PIN 20-23-ASC. Through interviews conducted and documentation reviewed, LPA was able to prove facility ensured the requirements set forth were met with guidance and continuous communication with Sacramento CDPH RN.

Based on the information gathered, the above allegations are found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted. LPA reviewed complaint with licensee, and will send a copy of report by email along with a read receipt. LPA informed admin to sign and return one copy by COB 5/5/2021.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Konnor Leitzell
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4