041373048-1-31-2022-25-AS-KHOS-CBBMB8-20220204082732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 041373048
Report Date: 01/31/2022
Date Signed: 01/31/2022 02:29:11 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
12/07/2021 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20211207163925

FACILITY NAME:	GISELLE'S CARE HOME #2		FACILITY NUMBER:	041373048
ADMINISTRATOR:	MEMORACION, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	2140 CERES AVENUE		TELEPHONE:	(530) 893-8078
CITY:	CHICO	STATE: CA	ZIP CODE:	95926
CAPACITY:	6	CENSUS: 6	DATE:	01/31/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	BETH MEMORACION		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff do not have required training.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact with Beth Memoracion, Licensee/Administrator. It was alleged that Staff do not have required training.

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 meeting with the licensee. Personal Protective Equipment (PPE) was worn: N-95 mask.

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-20211207163925

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 #2	FACILITY NUMBER: 041373048
	VISIT DATE: 01/31/2022

NARRATIVE

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Required Training for staff hired after 01/01/16 includes: Cultural Competency, Personal Care Services; Physical Limitations and Needs of the Elderly; Residents’ Rights; Dementia Care; Building and Fire Safety and Appropriate Response to Emergencies; Antipsychotic and Psychotropic Medications; Policies and Procedures Regarding Medications; and Postural Supports, Restricted Health Conditions and Hospice Care. In addition, training shall include shadowing a more experienced staff person for the required 16-hour initial training.

During the investigation, Ms. Memoracion and two staff persons were interviewed. Ms. Memoracion agreed that her two newest staff persons were lacking certain hours of training. Courses and hours that were lacking are as follows:

Cultural Competency;
Physical Limitations and Needs of the Elderly (2 hours required, 1 hour received);
Dementia Care (6 hours required, 1 hour received); and
Postural Supports, Restricted Health Conditions and Hospice Care.

During the process of this complaint, Ms. Memoracion has ensured and has provided her staff persons with the required training; thus, the plan of correction will have been completed.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be Substantiated. Health and Safety Code 1569.625 is being cited on the attached LIC 9099D. Appeal rights were provided, and the exit interview 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-20211207163925

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 #2	FACILITY NUMBER: 041373048
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 HSC 1569.625	1 2 3 4 5 6 7	Health and Safety Code 1569.625 This training shall be administered on the job, or in a classroom setting, or both, and may include online training. The licensee did not ensure that her staff had the required training	1 2 3 4 5 6 7	The licensee met the requirements to ensure that her staff persons received the training and certificates were reviewed. No further plan of correction is required.
	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)

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