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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 041370643
Report Date: 08/03/2021
Date Signed: 08/05/2021 06:12:05 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
03/15/2021 and conducted by Evaluator Misty Valencia
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210315133050
FACILITY NAME:COUNTRY HOUSEFACILITY NUMBER:
041370643
ADMINISTRATOR:SKAGGS, DANIELFACILITY TYPE:
740
ADDRESS:966 KOVAK COURTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:20CENSUS: 17DATE:
08/03/2021
UNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Lynette Dorenzo Lincensee and Administrator Markie HardestyTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff administered wrong medications to resident twice which resulted in hospitalization
Staff failed to seek medical attention for the resident in a timely manner
Staff failed to administer resident's medication as prescribed
Staff failed to safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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On 07/28/21, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegations and met with Lynette Dorenzo Lincensee. Prior to initiating the complaint 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 facility 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: Surgical Mask. Additionally, LPA was screened by care staff.

continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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 8
Control Number 25-AS-20210315133050
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: 08/03/2021
NARRATIVE
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Staff failed to seek medical attention for the resident in a timely manner and Staff failed to administer resident's medication as prescribed.

During interviews with Administrator (Admin), six (6) staff, seven (7) residents and reviewed records, it was determined that, staff failed to seek medical attention for the resident in a timely manner, and staff failed to administer resident's medication as prescribed to be substantiated. On 03/23/2021, LPA Jaclyn Avila interviewed Admin. Admin acknowledged that R1 was given the wrong medications on 03/11/2021 and 03/14/2021 by med techs S3 and S4, respectively. Admin further stated that, Admin did contact R1’s primary care provider and LPA Avila, regarding the 03/11/2021 medication error. However, Admin left a voicemail, but did not contact Emergency Personnel Services (ES) at that time. 0n 03/11/2021 at 9:02am Admin contacted LPA Avila to report the medication error for R1. Admin stated that they had not yet contacted ES. LPA directed Admin to contact ES immediately, instead of contacting LPA beforehand to report the error. Records and statements found that on 03/1/2021 at approximately 08:30am R1 was given the wrong medications. Statements further indicated that ES were called at approximately at 9:10am and arrived at the facility 9:15am. The preponderance of evidence standard has been met. The allegations are substantiated

Staff administered wrong medications to resident twice which resulted in hospitalization During this investigation LPA interviewed Administrator (Admin), six (6) staff, seven (7) residents, and reviewed records. It was determined that staff administered wrong medications to resident twice which resulted in hospitalization to be substantiated. Through interview with Admin and records reviewed it was found that the allegation did occur. On 07/23/2021 Admin stated that R8’s medications, which included Aspirin 81mg, Cymbalta 30mg, Lisinopril 10 mg, Loratadine 10mg, Omeprazole 20mg, Gabapentin 300mg, Lorazepam .5 and half a Norco tab 5/325mg were given to R1 by S3 at approximately 8:30am on 03/11/2021. Furthermore, Admin acknowledged that R9’s following medications were given to R1 in error on 03/14/2021 Donepezil 10mg, Mirtazapine 7.5mg, Trazadone 50mg, and Memantine by S4 at 8:30pm. Both medication errors causing R1 being transported to the local hospital for observation. R1 was not admitted only released the same day with no changes in condition.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 25-AS-20210315133050
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: 08/03/2021
NARRATIVE
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R1’s prescribed medications include the following; Metronidazole Topical .75% applied qd prn, Carbidopa-Levodopa 25mg-100mg 1 tablet my mouth three times daily, MiraLAX 1tsp prn, Prilosec OTC 20mg1 tab orally two times a day, Tylenol gel tab extra strength 1q six hours, Voltaren Topical 1% applied topical two times daily, Vitamin D 1000iu, Multi vitamin daily, nitro 100mg orally one time daily, Zofran 4mg one tablet every eight hours, Lasix 40mg one tablet daily, Clonazepam .5 half tablet morning/half tablet midday/half tab nightly, Levothyroxine 75mcg one tablet by mouth daily, Spironolactone 25mg orally once a day, and Ciclopirox Topical 1% 5ml applied two times daily. R8’s prescribed medications include the following; Levothyroxine 50mg taking one tablet my mouth before breakfast, Probiotic taken one tablet by mouth daily, Aspirin taken one by mouth daily, coq10 200 mg taken one tablet my mouth daily, Duloxetine 30mg taken one tablet by mouth daily, Lisinopril 10mg taken one my mouth daily, Omeprazole 20mg taken one my mouth daily Gabapentin 300mg taken three times by mouth daily, Lorazepam .5mg taken my mouth three times daily, Hydro/Apap 5-325mg taken half a tab by mouth four times daily. R9’s prescribed medications include the following; Mirtazapine 7.5mg taken one tab at bedtime, Donepezil taken one tab at bedtime, Trazadone 50mg taken one tab at bedtime, Memantine taken one tab at bedtime. Interview with Admin, who admitted that the medications were given to R1 in error and has since trained all staff with their new medication policy. The preponderance of evidence standard has been met. The allegations are substantiated

Staff failed to safeguard resident's personal belongings

During this investigation LPA interviewed Administrator (Admin), six (6) staff, seven (7) residents, and reviewed records, it was determined that Staff failed to safeguard resident's personal belongings to be substantiated. On 07/23/2021 Admin stated that another resident was using R1’s wheelchair (WC) and floormat. On 03/03/2021 while family was picking up R1 to transport R1 to a physician’s appointment, the WC was dirty with dried up food and in poor condition. When asked in regard to the WC, Admin stated that another resident had R1’s WC. On 03/03/03/2021 R1’s floor mat/fall alarm was removed from R1’s room by staff who believed that it did not belong to R1. The preponderance of evidence standard has been met. The allegations are substantiated

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the aforementioned allegations are found to be Substantiated. California Code of Regulations, Title 22 is being cited on the attached LIC 9099D. Appeal rights are provided, and a closure interview was conducted.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 25-AS-20210315133050
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care -The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
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Licensee agrees to send in written plan on how facility will ensure that residents are provided medical care in a timely manner POC due date 08/06/2021
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Based on a records reviewed and interviews, facility staff did not seek medical attention in a timely manner for R1. This poses an immediate health and safety risk to residents in care.
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Facility to send in proof that staff have been trained regarding requirement by 8//06/21
Type A
08/06/2021
Section Cited
CCR
87465(c)(2)
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Incidental Medical and Dental Care Services. Once ordered by the physician, medications shall be given in accordance with the physician’s directions. This requirement is not met as evidenced by:
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Licensee agrees to send in written plan on how facility will ensure that all staff are retrained in medication administration. POC due date 08/06/2021
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Facility incorrectly gave R1, R2's medications on 03/11/21 and R1, R3's medications on 3/14/21. R1 required emergency services at an area hospital. This poses an immediate health and safety risk to residents in care..
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Facility to send in proof that staff have been trained regarding requirement by 8//06/21
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 25-AS-20210315133050
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited
CCR
87217(b)
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Safeguards for Resident Cash, Personal Property, and Valuables(b)Every facility shall take appropriate measures to safeguard residents' property...This requirement was not met as evidence by:
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Licensee agrees to submit a Statement of Understanding relative to staff procedures implemented to ensure personal property will be safeguarded at all times. POC due date 08/06/2021
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Based on a records reviewed and interviews: facility did not safe guard R1's belongings, (R1)’s wheelchair was being used by another resident in care. This poses a potential health and safety risk to residents in care.
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Facility to send in proof that staff have been trained regarding requirement by 8//06/21
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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
03/15/2021 and conducted by Evaluator Misty Valencia
COMPLAINT CONTROL NUMBER: 25-AS-20210315133050

FACILITY NAME:COUNTRY HOUSEFACILITY NUMBER:
041370643
ADMINISTRATOR:SKAGGS, DANIELFACILITY TYPE:
740
ADDRESS:966 KOVAK COURTTELEPHONE:
(530) 342-7002
CITY:CHICOSTATE: CAZIP CODE:
95973
CAPACITY:20CENSUS: 17DATE:
08/03/2021
UNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Lynette Dorenzo Lincensee and Administrator Markie HardestyTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff caused an injury to a resident
Resident sustained injures while in care
Staff failed to return resident's personal belongings
Staff failed to notify resident's authorized representative of incidents
INVESTIGATION FINDINGS:
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3
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5
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13
On 07/28/21, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegations and met with Lynette Dorenzo Lincensee and Administrator Markie Hardesty. Prior to initiating the complaint 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 facility 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: Surgical Mask. Additionally, LPA was screened by care staff.

continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 25-AS-20210315133050
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: 08/03/2021
NARRATIVE
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Staff caused an injury to a resident

Resident sustained injures while in care

During interviews with Administrator (admin), 6 staff, 7 residents and records reviewed, it was determined that Staff caused an injury to a resident and Resident sustained injures while in care to be un-substantiated. Through interviews with admin, 6/6 staff and 7/7 residents it was found that the allegation did not occur. Interview with admin, 6/6 staff, and 7/7 residents all reported that staff has never been rough or caused injury to the residents. R1 did have scrape but when asked R1 reported R1 was not sure how R1 received the scrape. 6/6 staff reported that they never witnessed or heard about staff causing injuries to residents. 7/7 residents reported that they never had any issues with any of the staff. The preponderance of evidence standard has not been met. The allegations is un-substantiated.

Staff failed to return resident's personal belongings

During interviews with Administrator (admin), 6 staff, 7 residents and records reviewed, it was determined that Staff failed to return resident's personal belongings to be un-substantiated. Through interview with admin, it was found that the allegation did not occur. Interview with admin, who stated that the family wanted to come and pick up R1’s belongings in an hour after R1 was removed from the facility by family. The facility has a policy to count all belongings and medication before releasing property. The facility was not able to get R1’s property count within that hour. The family was able to pick up property later that afternoon. 6/6 staff and 7/7 resident interviews concluded that they have never had any issues or witnessed any issues regarding the return of personal belongings. The preponderance of evidence standard has not been met. The allegation is un-substantiated

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20210315133050
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: 08/03/2021
NARRATIVE
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Staff failed to notify resident's authorized representative (AR) of incidents

During interviews with Administrator (admin), 6 staff, 7 residents and records reviewed, it was determined that Staff failed to notify resident's authorized representative of incidents to be un-substantiated. Through interview with admin, it was found that the allegation did not occur. Interview with admin, who stated that family are always notified of any changes, incidents and ES contacts. LPA was not able to contact AR to verify if AR was notified regarding the incidents that happened. The preponderance of evidence standard has not been met. The allegation is un-substantiated

Based on the information obtained, records reviewed, and interviews conducted, the above allegations are Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are Unsubstantiated.

An exit interview was conducted, report given and no citations given at this time.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8