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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345003004
Report Date: 08/01/2024
Date Signed: 09/05/2024 12:31:31 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
01/16/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240116101651
FACILITY NAME:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(408) 218-5197
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Persida PopTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff did not ensure reporting requirements were followed
Staff did not ensure medications were dispensed in a timely manner
INVESTIGATION FINDINGS:
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On 8/1/24 Licensing Program Analyst (LPA) Kevin Mknelly spoke to Persida Pop, Administrator to deliver complaint findings for the above allegation.

LPA reviewed resident records, facility records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

While R1 was a resident at the facility, R1 experienced seizures/ hospitalization on 12/14/23, a skin tear on 1/5/24 and a hospitalization for UTI on 1/15/24. These incidents were not reported to CCL as required.

During the course of this investigation, several other violations are noted and will be reported on in a subsequent Facility Evaluation Report.

Report continued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 6
Control Number 59-AS-20240116101651
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: LITTLE BROOK CARE HOME
FACILITY NUMBER: 345003004
VISIT DATE: 08/01/2024
NARRATIVE
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Staff did not ensure medications were dispensed in a timely manner- On 8/29/24, LPA conducted a follow-up visit to the facility in response to additional information regarding R1 not receiving a prescribed medication.
Home Health records noted that R1 was prescribed Modafinil on 9/15/23.
R1 was then admitted to one of the licensee's homes in December 2023. R1 was transferred to this home on 1/2/24.
At the time of admission, the licensee received a print out from R1's treating hospital, that, though not a signed physician's order, did list Modafinil as one of R1's medication- with a notation that the medication cannot be "refilled at this time." The list was printed on 12/4/23.
In interview with the Administrator, Persida Pop, on 8/29/23, Administrator stated that they thought the Modafinil was discontinued. Administrator did not contact the physician for clarification nor a discontinue order.
In January 2024, R1's responsible party contacted R1's physician regarding the need for Modafinil. A new order was written and the medication was delivered on 1/11/24. LPA's review of the facility's Medication Administration record (MAR) for R1, did not record Modafinil administred until 1/13/24.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Administrator . Copy of this report and appeal rights provided.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
01/16/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240116101651

FACILITY NAME:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(408) 218-5197
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Persida PopTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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-Resident sustained multiple unexplained injuries while in care
-Staff did not ensure catheter care was provided to resident in care

INVESTIGATION FINDINGS:
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On 8/1/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with Persida Pop.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

Resident sustained multiple unexplained injuries while in care- R1 was noted in medical records to at times experience agitation, uncontrolled movements and was on blood thinners. R1 was seen regularly by home health who did not note concerns regarding bruising experienced by R1.

Report continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
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 6
Control Number 59-AS-20240116101651
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: LITTLE BROOK CARE HOME
FACILITY NUMBER: 345003004
VISIT DATE: 08/01/2024
NARRATIVE
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Staff did not ensure catheter care was provided to resident in care- Home health records noted that staff are aware of monitoring and emptying requirements of R1’s catheter. Health issues such as bleeding or UTI’s were monitored and medical care was provided by health care professionals as needed.

As a result of this investigation, LPA finds allegation to be (US)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 with administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/16/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20240116101651

FACILITY NAME:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(408) 218-5197
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
08/01/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Persida PopTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Resident developed a stage 2 pressure injury while in care
INVESTIGATION FINDINGS:
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On 8/1/24, Licensing Program Analyst (LPA) Kevin Mknelly LPA Mknelly arrived and met with Administrator to deliver investigation findings.

LPA reviewed staff records and facility record.
LPA finds that facility met Tittle 22 requirements.
Home Health records for R1 were collected and reviewed by LPA Mknelly. Home Health records showed that at admission R1 had a closed pressure injury and a stage 2 pressure injury. Throughout R1’s care are the facility from 12/13/23- 1/15/24, Home health wound care nurses noted that both pressure injuries remained stable.

This agency has investigated the above complaint allegations. We have found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Exit interview conducted and report provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 59-AS-20240116101651
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: LITTLE BROOK CARE HOME
FACILITY NUMBER: 345003004
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2024
Section Cited
CCR
87465
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Incidental Medical and Dental Care- (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.
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Licensee licensee will arrange for an audit/ consultation from a licenseed professional familiar with medication requirements in RCFEs by the POC 9/17/24 with the consultation to occur by 9/30/24.
Confirmation of the audit to be submitted by 9/17/24.
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This requirement was not met based on records and interviews that found R1 did not have written orders, licensee did not confirm orders and licensee did not promptly administer medications when received.
This posed an immediate risk to R1.
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Request Denied
Type B
08/01/2024
Section Cited
CCR
87211
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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as …: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence … (D) Any incident which
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Licensee has had this issue addrerssed previously while thes was investigated.
Previous POCs have been cleared.
No further issues are present at this time.
POC cleared at this visit.
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threatens the welfare, safety or health of any resident, … This requirement was not met in two incidents for R1 that were not reported to CCLD. This posed a potential risk.
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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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6