347002549-8-12-2022-25-AS-LMUZ-CHBPE6-20220815111434

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347002549
Report Date: 08/12/2022
Date Signed: 08/12/2022 02:38:10 PM

Substantiated

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
04/07/2022 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 25-AS-20220407105548

FACILITY NAME:	AFABLE HOME CARE II		FACILITY NUMBER:	347002549
ADMINISTRATOR:	AFABLE, NICOLASA O.		FACILITY TYPE:	740
ADDRESS:	4080 PALM AVENUE		TELEPHONE:	(916) 258-3737
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95842
CAPACITY:	6	CENSUS: 5	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Nicolasa Afable		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to resident while in care.
Licensee did not do a proper assessment of resident.

INVESTIGATION FINDINGS:

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On 08/12/22, Licensing Program Analyst (LPAs) Talwinder Bains and Michael Hood conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with administrator Nicolasa Afable. Prior to initiating the complaint visit, LPAs completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPAs ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask /N-95 mask. Additionally, LPAs was screened with temperature at the facility upon arrival.

The department conducted records review and interviews.

**Report continued on LIC9099-C**

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

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 7

Control Number 25-AS-20220407105548

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: AFABLE HOME CARE II	FACILITY NUMBER: 347002549
	VISIT DATE: 08/12/2022

NARRATIVE

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Allegation:
Staff did not provide adequate supervision to resident while in care.

The department conducted interviews regarding resident (R1) leaving the facility unattended on 03/28/22, at approximately 5:00am. Facility administrator and staff confirmed R1 was gone approximately 30-40 minutes. Based on interviews, once staff realized R1 was missing, Facility staff found R1 about 2 blocks from the facility and brought R1 back to facility. Facility called 9-1-1 to notify of R1’s AWOL. However, once R1 was located, the facility called off EMS. Facility was aware that R1 has diagnosis of dementia and cannot leave the facility unassisted. This was the first AWOL incident for R1 since his admission to the facility.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Allegation:
Licensee did not do a proper assessment of resident.

The department conducted interviews and records review regarding proper assessment was not completed for resident (R1) by facility. During interview, facility administrator stated that R1 was admitted to facility on 03/27/22. Per Administrator, R1’s responsible parties were supposed to come to facility on 03/28/22 to finish all new admission paperwork. It was concluded that no pre-admission assessment or new admission paperwork was completed by facility per RCFE requirement on/before R1 admission to the facility on 03/27/22.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Administrator and a copy of this report and appeal rights were provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 25-AS-20220407105548

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: AFABLE HOME CARE II	FACILITY NUMBER: 347002549
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/14/2022 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705- Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Current Licensee/Administrator conducted shall staff training on keeping a closer watch on any residents that may have a tendency to AWOL and document any changes in condition. Documentation of training sholud be provided to LPA by POC date-08/14/22.
	8 9 10 11 12 13 14	Based on interviews conducted and record review , the Licensee did not ensure that resident (R1) was unable to leave the facility unassisted, on 03/28/22, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 08/26/2022 Section Cited CCR 87457(c)	1 2 3 4 5 6 7	87457(c)-Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.	1 2 3 4 5 6 7	Licensee shall submit statement of understanding regarding this regulation in writing and submit the documents to LPA by POC date-08/26/22. Also, Licensee will make sure that pre-assessment shall be completed for all new residents prior to admission to the facility.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on record review and interviews, Licensee did not do pre admission or new admssion assessment for R1 at time of R1 admission to the facility on/before 03/27/22, which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14

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: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
04/07/2022 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 25-AS-20220407105548

FACILITY NAME:	AFABLE HOME CARE II		FACILITY NUMBER:	347002549
ADMINISTRATOR:	AFABLE, NICOLASA O.		FACILITY TYPE:	740
ADDRESS:	4080 PALM AVENUE		TELEPHONE:	(916) 258-3737
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95842
CAPACITY:	6	CENSUS: 5	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Nicolasa Afable		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Facility alarm was not working properly at the time of resident's AWOL /Elopement incident.
Facility did illegal eviction of the resident.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 25-AS-20220407105548

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: AFABLE HOME CARE II	FACILITY NUMBER: 347002549
	VISIT DATE: 08/12/2022

NARRATIVE

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Allegation: Facility alarm was not working properly at the time of resident's AWOL /Elopement incident.

The department interviewed facility administrator regarding this allegation.Administrator stated that facility alarm system had no issues and it was working fine. Per Title 22 regulations, RCFE does not require to have any working alarm system for facility to take care of residents in care. However, facility needs to provide proper care and supervision for residents in care, which facility did not do since R1 was able to AWOL from the facility on 03/28/22.

Allegation: Facility did illegal eviction of the resident.

The department interviewed facility administrator regarding this allegation. Based on record review and interviews, department has concluded that R1 was admitted to this facility on 03/27/22 and was sent out to hospital on 03/28/22 after a fall incident. Facility did not verbalize anything to the hospital or R1’s family that R1 could not come back once he got discharged from hospital. There was no notice of any eviction provided to R1 and/or R1’s responsible party.

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

A copy of this report has been provided to facility. Exit interview conducted.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 7

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
04/07/2022 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 25-AS-20220407105548

FACILITY NAME:	AFABLE HOME CARE II		FACILITY NUMBER:	347002549
ADMINISTRATOR:	AFABLE, NICOLASA O.		FACILITY TYPE:	740
ADDRESS:	4080 PALM AVENUE		TELEPHONE:	(916) 258-3737
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95842
CAPACITY:	6	CENSUS: 5	DATE:	08/12/2022
		UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Nicolasa Afable		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Resident has AWOL/ Elopement incident from the facility sustaining an injury to the resident.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 25-AS-20220407105548

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: AFABLE HOME CARE II	FACILITY NUMBER: 347002549
	VISIT DATE: 08/12/2022

NARRATIVE

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Allegation:

Resident has AWOL/ Elopement incident from the facility sustaining an injury to the resident.

R1 was admitted to this facility on 03/27/22. Within the 24-hour time frame, R1 had two incidents; R1 AWOL’d from the facility on the morning of 3/28/2022 and was found shortly after. Facility called EMS but EMS did not take R1 to hospital after R1 was evaluated and first aid was provided. On the same day (03/28/22) around 3pm, R1 had what was believed to be a ground level fall from R1’s bed to the floor. Facility contacted 9-1-1 and R1 was taken to hospital for treatment. Upon R1’s arrival to the hospital, R1 sustained a right sided subdural hematoma, laceration on upper lip and frontal scalp hematoma. Based on medical records reviewed, it is unclear to determine if the injuries R1 sustained were due to the AWOL or the fall.

Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022

LIC9099 (FAS) - (06/04)

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