041373047-1-31-2022-25-AS-KHOS-CBBLX6-20220204080813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 041373047
Report Date: 01/31/2022
Date Signed: 01/31/2022 02:31:10 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
12/06/2021 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20211206155657

FACILITY NAME:	GISELLE'S CARE HOME #1		FACILITY NUMBER:	041373047
ADMINISTRATOR:	MEMORACION, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	1156 MANZANITA AVENUE		TELEPHONE:	(530) 893-1716
CITY:	CHICO	STATE: CA	ZIP CODE:	95926
CAPACITY:	6	CENSUS: 4	DATE:	01/31/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	BETH MEMORACION		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

A resident's room has bed bugs.
Staff are not keeping facility free from pests.

INVESTIGATION FINDINGS:

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

Donna Gurriere, Licensing Program Analyst was in contact and met with Beth Memoracion, Licensee/Administrator. It was alleged that A resident's room has bed bugs and Staff are not keeping facility free from pests.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

**continued**

Substantiated

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: 01/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022

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-20211206155657

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: 01/31/2022

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**

A resident's room has bed bugs.
The licensee advised that there were bed bugs on the resident's chair and that she moved the resident's chair outside of the facility. The licensee advised that she had Gecko Pest Control come to the facility to spray the resident's chair, bed area and carpets. The licensee has the resident's chair outside of the facility to dispose of. Bed bugs are no longer in the resident's room or anywhere else in the facility.

Staff are not keeping facility free from pests.
The licensee reported that she had Gecko Pest Control come to the facility to set traps for the pests in the garage. The licensee stated that the pest control did trap a rodent and the rodent has been removed. The licensee advised that the pest control company has recently been to the facility three times.

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

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20211206155657

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: 01/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/31/2022 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. The licensee did not ensure that the facility was safe from pests and rodents.	1 2 3 4 5 6 7	The licensee has agreed to ensure that the facility is safe from pests and rodents and has hired a pest control company. Licensee has submitted the invoice from the pest control company, no further plan of correction.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3