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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700264
Report Date: 11/14/2024
Date Signed: 11/27/2024 12:00:10 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
08/05/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240805094518
FACILITY NAME:JEWELL HOME CAREFACILITY NUMBER:
392700264
ADMINISTRATOR:RALH, MONICAFACILITY TYPE:
740
ADDRESS:1141 S. VAN BUREN STREETTELEPHONE:
(209) 323-4972
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 6DATE:
11/14/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Nordia Heywood and Monica PlowdenTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 11/14/2024 by Licensing Program Analyst (LPA) Charlie Yang and was met by the facility live-in caregiver, Nordia Heywood, who was briefly interviewed at this time.
This LPA requested that she go ahead and contact the facility designated Administrator, Monica Plowden, to inform her that CCL was present at this time. The facility designated Administrator, Monica Plowden, arrived shortly thereafter to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 6 residents.
It was learned that there were (3) residents under the care of hospice at this time. This facility is approved to be able to accept and retain up to (4) residents under hospice care at any given time.
This LPA requested to review the facility resident files at this time.
A review of (6) facility resident files was conducted and noted on the following LIC 858.
A brief tour of the facility was conducted as well.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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 2
Control Number 27-AS-20240805094518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JEWELL HOME CARE
FACILITY NUMBER: 392700264
VISIT DATE: 11/14/2024
NARRATIVE
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Based on interviews conducted during the course of this investigation, it was learned that R1 did not have any immediate family or relatives nearby who were present in R1's daily life.
Based on a review of the facility forms and documents, it was learned that a Client/Resident Personal Property and Valuables, LIC 621, was completed and signed by all parties dated on 04/01/2022.
It was learned that R1 did have a distant relative who resided out of state but was unable to visit and see R1 on a regular basis.
It was learned that upon R1's passing, R1's distant relative did relinquish all property and belongings to this facility and facility representatives. This was evidenced by an email that was sent directly to this facility email address, JewellHomeCare@gmail.com, dated on 08/28/2024.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited during today's complaint visit at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2