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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700799
Report Date: 07/05/2022
Date Signed: 07/06/2022 11:35:24 AM

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
06/20/2022 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20220620110331
FACILITY NAME:STARGLOW RCFEFACILITY NUMBER:
342700799
ADMINISTRATOR:HOUSTON, ANGELINEFACILITY TYPE:
740
ADDRESS:35 STARGLOW CIRCLETELEPHONE:
(916) 603-8434
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY:6CENSUS: 6DATE:
07/05/2022
UNANNOUNCEDTIME BEGAN:
10:57 AM
MET WITH:Angeline HoustonTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff did not prevent resident from sustaining an injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/5/22 at 10:45am to conclude the complaint investigation. LPA met with Caregiver Arlo Arcega and stated the purpose of the visit. Within 15 minutes the Administrator Angeline Houston arrived to assist with todays visit.

LPA reviewed a copy of incident report submitted to Community Care Licensing (CCL) and prescriptions for medication relating to behaviors, prescription for bed alarm pad, and half rail. LPA conducted interviews of Staff #1 (S1-S2) and Administrator on 6/23/22. During todays visit, LPA interviewed S1-S4 and Administrator. LPA reviewed a copy of the after visit summary of the visit conducted by the physician on 6/17/22. This document indicated that Resident #1 (R1) has a history of scratching face, unwitnessed event that later was determined during transfer mandibular area may have been hit on bed rail and developed bruising later, and there was blood reported inside the mouth area.
Unsubstantiated
Estimated Days of Completion: 30
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
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-20220620110331
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: STARGLOW RCFE
FACILITY NUMBER: 342700799
VISIT DATE: 07/05/2022
NARRATIVE
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Interviews revealed that R1 has a history of biting inside of mouth, being agitated and attempting to get out of bed alone without assistance. The Administrator deemed the injury to be minor but requested a physician visit to be sure medical attention was not needed. During the 6/17/22 physician visit, there was no medical needed nor was there any medications prescribed.

Based on a review of documents and interviews, it has been determined that R1 slide out of bed and the hoyer lift was not used to transfer back to bed. An injury occurred on the side of the mouth area but it is not clear if it was due to biting inside the mouth, scratching the face, or from being lifted back into bed without the use of the hoyer lift, the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found 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.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2