041373048-1-4-2022-25-AS-LMUZ-CDDMJ8-20220411093841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 041373048
Report Date: 01/04/2022
Date Signed: 01/04/2022 03:22:59 PM

Substantiated

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
12/28/2021 and conducted by Evaluator Jaclyn Avila

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211228084336

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: 5	DATE:	01/04/2022
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Administrator Beth Memoracion		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident's exit door is blocked at the facility.

INVESTIGATION FINDINGS:

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1/4/2022 at 2:15 PM Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to conduct a complaint investigation. LPA met with licensee/administrator Elizabeth Memoracion and explained the purpose of the visit. Prior to initiating the complaint investigation 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 staff 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: PAPR

LPA explained the reason for the visit was to investigate the above allegation.

Cont'd on 9099-C

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211228084336

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: 01/04/2022

NARRATIVE

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Based on LPA's observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, 87307(d)(6)-Personal Accommodations and Services -All outdoor and indoor passageways and stairways shall be kept free of obstruction.

LPA conducted an inspection of 5 resident rooms. LPA observed 1 of 5 rooms known as room #3. In room #3, LPA observed a large desk obstructing an outdoor passageway. LPA spoke with administrator who had knowledge however stated the resident requested the desk be placed there.

The following deficiencies were cited per Title 22 of the California Code of Regulation See LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211228084336

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: 01/04/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/05/2022 Section Cited CCR 87307(d)(6)	1 2 3 4 5 6 7	87307(d)(6)-Personal Accomadation and Services: The following space and safety provisions shall apply to all facilities:All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based upon observation and	1 2 3 4 5 6 7	Licensee agrees to remove the obstruction by close of business on 01/05/2022. Licensee will send a photo to LPA once obstruction is removed.
	8 9 10 11 12 13 14	interview the Licensee failed to keep 1 of 5 outdoor bedroom passageways free from obstruction. This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.	8 9 10 11 12 13 14
	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: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022

LIC9099 (FAS) - (06/04)

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