041370643-5-4-2021-25-AS-KHOS-C2WQ7G-20210511115506

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 041370643
Report Date: 05/04/2021
Date Signed: 05/04/2021 12:34:36 PM

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
01/05/2021 and conducted by Evaluator Donna Gurriere

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210105101103

FACILITY NAME:	COUNTRY HOUSE		FACILITY NUMBER:	041370643
ADMINISTRATOR:	SKAGGS, DANIEL		FACILITY TYPE:	740
ADDRESS:	966 KOVAK COURT		TELEPHONE:	(530) 342-7002
CITY:	CHICO	STATE: CA	ZIP CODE:	95973
CAPACITY:	20	CENSUS: 19	DATE:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	01:00 AM
MET WITH:	MARKIE HARDESTY		TIME COMPLETED:	02:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

A resident sustained an abrasion wound across the midline due to improper restraints.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Donna Gurriere, Licensing Program Analyst (LPA) was in contact with Markie Hardesty, Administrator. A physical visit could not be made due to the orders in place regarding the Corvid Virus. It was alleged that A resident (Resident 1) sustained an abrasion wound across the midline due to improper restraints.

On 04/30/21 an investigation was completed by the Investigations Branch for a complaint that was received on 01/05/21. During the investigative process, Resident 1, numerous care providers, nursing staff and the physician were interviewed. In addition, several medical documents were received and reviewed.

**continued**

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

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-20210105101103

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: COUNTRY HOUSE	FACILITY NUMBER: 041370643
	VISIT DATE: 05/04/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

**continued**

It was reported that Resident 1 sustained an abrasion wound across the midline (stomach area) which was determined to have been caused by her pants being too tight. It was also reported by care providers that the facility does not use any type of restraints. It was stated that the facility staff only use a gait belt to assist residents with their mobility, that the abrasion did not match the use of the gait belt and that a gait belt was not used on Resident 1.

.This agency has investigated the complaint alleging that A resident (Resident 1) sustained an abrasion wound across the midline due to improper restraints. We have found the complaint was Unfounded, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2