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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005861
Report Date: 06/21/2021
Date Signed: 06/21/2021 10:21:12 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, 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
06/04/2021 and conducted by Evaluator Bethany Huusfeldt
COMPLAINT CONTROL NUMBER: 25-AS-20210604155852
FACILITY NAME:GRANDMA'S HOME IIFACILITY NUMBER:
347005861
ADMINISTRATOR:MEHEDINTI, MIHAILFACILITY TYPE:
740
ADDRESS:6520 MILES LANETELEPHONE:
(916) 571-5521
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:4CENSUS: 4DATE:
06/21/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mihail Mehedinti, AdministratorTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Resident sustained injuries while in care
Facility staff hit resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Huusfeldt Mirlohi arrived unannounced to deliver findings into allegations listed above. LPA met with administrator Mihail Mehedinti during today's visit. LPA 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.
During the complaint investigation LPA interviewed residents, staff, responsible parties and relevant parties and conducted a file review. LPA investigated the allegation, "resident sustained injuries while in care". LPA toured the facility and interviewed 4 of 4 residents. Interview with relevant party suggest resident sustained injuries while transferring from wheelchair.
Continuation on 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Huusfeldt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
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 25-AS-20210604155852
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: GRANDMA'S HOME II
FACILITY NUMBER: 347005861
VISIT DATE: 06/21/2021
NARRATIVE
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LPA conducted interviews with staff in which they stated resident did have a small cut on their shin however resident is independent with continence care and caregiver was not present during the incident. Due to inconsistent information gathered from interviews, LPA finds allegation to be UNSUBSTANTIATED.

LPA investigated the allegation, "Facility staff hit resident". Interview with relevant party suggest caregiver grabbed residents arms tightly and aggressively. During facility inspection, LPA did observe discoloration on resident arms. A file review was completed and interviews with responsible party show resident is on blood thinner medications which may cause bruising easily. LPA interviewed staff if which they stated they have not grabbed resident by the arms at any time. Due to inconsistent information gathered from interviews, LPA finds allegation to 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 concluded.
SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Bethany Huusfeldt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC9099 (FAS) - (06/04)
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