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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002947
Report Date: 01/16/2025
Date Signed: 01/16/2025 01:07:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2024 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20241014091311
FACILITY NAME:J & H CARE HOMESFACILITY NUMBER:
345002947
ADMINISTRATOR:SALMAN, RASHAFACILITY TYPE:
740
ADDRESS:8529 ARROWROOT CIRCLETELEPHONE:
(916) 905-8038
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:6CENSUS: 5DATE:
01/16/2025
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Administrator- Rasha SalmanTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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Resident developed pressure injury while in care
Staff are not meeting residents needs
INVESTIGATION FINDINGS:
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On 01/16/2025, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver findings regarding a complaint the Department received on 10/14/2024. LPA met with Administrator Rasha Salman and explained the purpose of the visit.

During the course of the investigation, the Department conducted interviews and obtained pertinent documents relevant to the complaint investigation.

Please continue to LIC9099C…

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
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 3
Control Number 59-AS-20241014091311
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: J & H CARE HOMES
FACILITY NUMBER: 345002947
VISIT DATE: 01/16/2025
NARRATIVE
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On 08/09/2024 it was documented in Resident #1 (R1s) medical records that there was no pressure injury on R1. On 09/16/2024, R1 moved into the facility. Staff #1 (S1) stated that when R1 arrived at the facility they had no open pressure injuries. On 10/01/2024, facility staff had reported to Home Health staff that R1 had developed pressure injuries. On 10/02/2024 R1s pressure injuries were assessed by Home Health staff and it was noted that R1 had two (2) stage three pressures injuries in their sacral region. One pressure injury was four centimeters by two centimeters and the other was five centimeters by two centimeters. Per Home Health facility staff was instructed to reposition R1 every one to two hours. On 10/06/2024 R1 was admitted to the hospital. While at the hospital, it was documented that R1 had a pressure injury that was eight centimeters by six centimeters.

Interview with R1 indicated that they would lay in bed for four or more hours without being repositioned. R1 stated when they were repositioned, staff were rough with them. Interviews with staff revealed R1 needed to be repositioned every two to four hours. Two out of three staff were unaware of R1s injuries.

Based on the information obtained, the facility did not meet R1’s needs resulting in R1 developing pressure injuries while in care, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 regulations, Division 6, are being cited on the attached LIC 9099D

Exit interview conducted and a copy of the report and appeal rights were left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20241014091311
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: J & H CARE HOMES
FACILITY NUMBER: 345002947
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2025
Section Cited
CCR
87615(a)(1)
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87615(a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(1)Stage 3 and 4 pressure injuries.
This requirement t is not met as evidenced by:
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Licensee is to schedule a training on pressure injuries with an outside agency and submit proof of scheduled training to LPA by POC due date.
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Based on record review and interviews the licensee did not comply with the section cited above as the licensee retained R1 who had two (2) stage three (3) pressure injuries without an exception. This poses an immediate health and safety risk to residents in care.
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Type A
01/17/2025
Section Cited
CCR
87609(b)(2)
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87609(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met:
(2) The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care.
This requirement is not met as evidenced by:
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Licensee to come up with a plan to ensure residents receiving home health services will have their needs met as outlined in their care plans. Once plan is completed Licensee will have all staff review and sign then send to LPA by POC due date.
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Based on interviews the licensee did not comply with the section cited above as R1 was not repositioned or rotated as instructed by Home Health.
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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: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3