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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 041373047
Report Date: 07/28/2021
Date Signed: 07/28/2021 12:26:20 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
04/02/2021 and conducted by Evaluator Pheej Cheng
COMPLAINT CONTROL NUMBER: 25-AS-20210402090959
FACILITY NAME:GISELLE'S CARE HOME #1FACILITY NUMBER:
041373047
ADMINISTRATOR:MEMORACION, ELIZABETHFACILITY TYPE:
740
ADDRESS:1156 MANZANITA AVENUETELEPHONE:
(530) 893-1716
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY:6CENSUS: 3DATE:
07/28/2021
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Mildred Calma; StaffTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility failed to provide documents
INVESTIGATION FINDINGS:
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On 7/28/21 at 11:40 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint invesetigations visit regarding the allegation above. LPA Cheng met with staff Mildred Calma and explained reason for visit. Prior to initiating the 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 Administrator 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 facility staff Calma.

Continuation on LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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 3
Control Number 25-AS-20210402090959
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: GISELLE'S CARE HOME #1
FACILITY NUMBER: 041373047
VISIT DATE: 07/28/2021
NARRATIVE
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Based on staff interview statements and documents obtained, LPA determined that the above allegation occurred. LPA Avila's obtain S1's statement on 4/8/21 that the facility did in fact received the RP's document request via fax on 3/30/2021 and that it was mixed with other facility documents. Facility provided proof that RP's requested documents were sent via post office on 4/8/2021. Deficiency cleared during visit.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of report along with appeal rights were given.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20210402090959
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: GISELLE'S CARE HOME #1
FACILITY NUMBER: 041373047
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2021
Section Cited
HSC
1569.269(21)
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1569.269 Enumerated Rights; severability (21) To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by:
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Licensee mailed RP's requested documents on 7/8/21 and provided proof. Deficiency has been cleared during visit.
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Based on staff statement and documents obtained, Licensee did not provide 1 of 1 resident's requested document to RP which poses a potential health and safety risk to resident in care.
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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: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej ChengTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3