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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803499
Report Date: 10/26/2021
Date Signed: 10/26/2021 01:37:45 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/21/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20210521165957
FACILITY NAME:SILVER STARFACILITY NUMBER:
496803499
ADMINISTRATOR:KUMAR, AMIFACILITY TYPE:
740
ADDRESS:1966 DENNIS LANETELEPHONE:
(707) 595-3605
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:6CENSUS: 5DATE:
10/26/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ami Kumar/AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failing to meet residents care needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegation. LPA met with Ami Kumar and discussed the findings. It has been alleged that facility staff have not met the care needs of R1 in that R1 declined while in placement due to staff neglect. During the course of this investigation statements were taken from staff and witnesses; documents and medical records were obtained and reviewed; three site visits were made to the facility and one collateral visit to another facility. Based upon this investigation, the following determinations have been made: R1 is 95 with a history of recurrent illness; R1 did deteriorate while in placement at the facility; Records show that staff responded to R1's symptoms and did seek medical attention when necessary as well as making the required reports; Family reports R1's skin appeared well care for despite being bedridden; R1's condition worsened on April 24, 2021 but was not sent out until April 26, 2021; The available evidence suggests that the delay resulted from advice from hospital nurse who recommended allowing time to see if R1 would respond to a new course of medication. While the allegation may be true, based upon statements and records, there is not a preponderance of evidence to prove allegation did or, did not occur. Therefore, it is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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