347004430-3-2-2023-25-AS-KHOS-CPNSCF-20230306124525

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004430
Report Date: 03/02/2023
Date Signed: 03/02/2023 01:40:52 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
01/19/2023 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20230119110911

FACILITY NAME:	POPO'S PLACE		FACILITY NUMBER:	347004430
ADMINISTRATOR:	RACHEL MILES		FACILITY TYPE:	740
ADDRESS:	7672 EASTGATE AVENUE		TELEPHONE:	(916) 961-6248
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 5	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Luz Jimenez, caregiver		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident sustained an unexplained bruise while in care.
Staff scratched resident while in care.
Staff does not provide a comfortable temperature for resident in care.
Staff does not provide resident clothing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude the complaint investigation and deliver findings tp a complaint received 1/19/23 . LPA met with caregiver staff, Luz Jimenez, and explained purpose of inspection. Administrator was contacted but not able to be present. LPA observed (3) residents to be in the common areas and (2) residents to be in their room at the start of the inspection. The facility is licensed for (6) non-ambulatory residents and has a hospice waiver for (2). Currently, there are (0) residents on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 Department protocols and was wearing a surgical mask.

During the investigation, the Department interviewed House Manager, (2) care staff, (3) residents, including resident (R1), and R1’s representative. The Department took photos of R1’s clothing and socks and reviewed resident’s physician’s report, orders,charting notes and other documentation.

Resident (R1) has a diagnosis of Unilateral Primary Osteoarthritis on the left knee and generalized muscle weakness. The physician’s report does not indicate resident has a diagnosis of Dementia but states that resident can be confused or disoriented, needs assistance with all activities of daily living and is not able to leave the facility unassisted. House manager indicated that R1 is in the early stages of Dementia.

The results of the investigation are as follows:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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 5

Control Number 25-AS-20230119110911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: POPO'S PLACE	FACILITY NUMBER: 347004430
	VISIT DATE: 03/02/2023

NARRATIVE

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9099C(1)..Allegation: Resident sustained an unexplained bruise while in care.
Complaint alleges that staff mistreats her and was observed to have a bruise on her face.

Staff (S1) stated on 1/27/23 that resident (R1) did not have a bruise when she moved to the facility in December 2022 and has been trying to get used to using a wheelchair, and has bruising on her arm because of this. A second staff (S2) stated that she has not observed R1 to have any bruises on the face but only on her wrist area, stating "her arms are sensitive" as with all of the residents. Two (2) residents stated they have not observed any bruising unless the resident did it to themselves, stating "some of us bump our hands or wrists".

LPA Parks did not observe any bruise or marking's on resident's cheeks on 1/27/23. LPA Calzada did not observe any bruise or marking on resident’s face on 2/10/23 or on 3/2/23.

Resident’s family member stated “there is no truth to any bruising" by staff and both S1 and S2 are "very professional every time" he has visited. Complaint indicated that R1 was observed to have a bruise on her face on/around 1/19/23.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff scratched resident while in care.
Complaint alleges that staff scratched resident's face.

Resident stated to LPA on 1-27-23 that she was grabbed by her cheek by staff not that long ago; however, LPA did not observe any bruising on resident's face.

cont on 9099C(2)..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
01/19/2023 and conducted by Evaluator Sabrina Calzada

COMPLAINT CONTROL NUMBER: 25-AS-20230119110911

FACILITY NAME:	POPO'S PLACE		FACILITY NUMBER:	347004430
ADMINISTRATOR:	RACHEL MILES		FACILITY TYPE:	740
ADDRESS:	7672 EASTGATE AVENUE		TELEPHONE:	(916) 961-6248
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 5	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Luz Jimenez, caregiver		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff does not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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Allegation: Staff does not treat resident with dignity and respect.
Complaint alleges that staff mistreats resident (R1), yells at her, and she is fearful of being there.

Staff (S1) stated that resident (R1) is not combative but can become verbally aggressive and was frightened when she moved in. S1 stated resident prefers to have staff (S2) care for her, but will allow S1 to shower her. Interviews with (2) other residents indicated that, although staff can sometimes get tired from the job, they always treat them and other residents well. Resident's representative stated that staff is "very professional everytime" he has visited R1.

Based on information obtained, LPA Finsd the allegation to be UNFOUNDED- means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview with caregiver who is authorized to sign today's report. Copy of report left at facility.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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 5

Control Number 25-AS-20230119110911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: POPO'S PLACE	FACILITY NUMBER: 347004430
	VISIT DATE: 03/02/2023

NARRATIVE

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9099C(2).. One resident interviewed stated she has not observed staff to ever hit or scratch a resident(s). Another resident stated she has never observed any bruising on any resident(s) due to staff hitting them.

S1 stated on 1/27/23 that resident did not move in with any bruises but was frightened of her new living environment. S1 stated that resident can be verbally aggressive, does not like her (S1) and prefers to have staff (S2) provide care for her. S1 stated R1 will allow her to give her a shower.

Charting notes for resident R1 document that on 12-10-22 staff (S1) wrote that while attempting to stop resident from sliding out of bed, she “grabbed her arms and accidentally tore her skin… and patched it”. Notes say the “nurse came in to fix the wound’ with instructions to not remove the bandages and to let the wound dry out… the bandages will fall off”.

LPA Parks did not observe any bruise or marking's on resident's cheeks on 1/27/23. LPA Calzada did not observe any bruise or marking on resident’s face on 2/10/23 or on 3/2/23.

Based on information obtained, including a prior incident when S1 accidentally scratched R1, LPA finds the allegation to be UNSUBSTANTIATED- although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff does not provide a comfortable temperature for resident in care.
Resident complains of being cold.

House Manager stated on that she removed the vent cover from R1's room, on 1/28/23, the day following when she spoke to LPA Parks. House Manager stated the vent cover had been placed there by a prior resident which "may have been preventing the heat" from heating the room”. R1’s representative stated "there was a vent that was closed in (R1's) room, from the previous tenant, but it has since been reopened” and “my grandma is always cold”. S2 stated on 3/2/23 that there was a plastic cover over the vent in R1's room, but the temperature has always been fine as the door is always open. S2 stated that the temperature is currently the same as it was before with the cover". LPA observed the temperature to appear to be the same as the rest of the facility on 3/2/23, even with the window slightly open.
cont on 9099C(3)..

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 25-AS-20230119110911

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: POPO'S PLACE	FACILITY NUMBER: 347004430
	VISIT DATE: 03/02/2023

NARRATIVE

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9099C(3).. LPA Parks observed the inside temperature to be 74 degrees on 1/27/23 in the early afternoon. LPA Calzada observed the inside temperature to be 75*F on 2/10/23 and 74*F on 3/2/23.

Based on information obtained, LPA finds the allegation to be UNSUBSTANTIATED- although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Staff does not provide resident clothing.
Complaint alleges that R1 doesn’t have enough clothing other than a hospital gown.

All staff interviewed indicated that R1 moved to the facility with only a few items of clothing, including a robe and (2) tops. Resident Personal Property and Valuables (LIC621)was signed by resident’s POA on 12/14/22 with no items listed, including clothing. Staff interviews also revealed that the facility reached out to R1's responsible person on (2) to (3) occasions requesting R1 be provided with additional clothing for colder weather.

S2 stated that in addition to R1's representative bringing some additional clothing to R1, another resident, who was cleaning out, gave some of her clothing to R1. (2) residents interviewed confirmed that R1 was given some winter clothing from another resident who was cleaning out. Resident's representative confirmed that the facility did reach out to him requesting additional clothing and he brought some clothing over, stating he felt R1 had adequate clothing when she moved in. LPA Calzada observed additional clothing on 3/2/23 than what was in resident’s room and dresser on 1/27/23, based on photos taken.

Resident moved to the facility on/around the middle of December 2022. R1's charting notes indicate that R1's representative brought slippers, a blanket and a pair of pajamas over on 1/10/23 and S2 advised representative R1 needed more clothes. House manager stated that she brought some clothes to the facility for R1 on 1/28/23, after speaking with LPA on 1/27/23,. who stated it was the facility's responsibility to ensure that resident has sufficient clothing for the season and if the family is not responding, the facility can purchase the clothing and then issue a bill for the clothing.

Based on information obtained and it not being clear how soon facility reached out to R1's representative, LPA finds the allegation to be UNSUBSTANTIATED- although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Sabrina Calzada
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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