<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 041373048
Report Date: 05/31/2022
Date Signed: 05/31/2022 04:12:51 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
02/01/2022 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20220201115846
FACILITY NAME:GISELLE'S CARE HOME #2FACILITY NUMBER:
041373048
ADMINISTRATOR:MEMORACION, ELIZABETHFACILITY TYPE:
740
ADDRESS:2140 CERES AVENUETELEPHONE:
(530) 893-8078
CITY:CHICOSTATE: CAZIP CODE:
95926
CAPACITY:6CENSUS: 0DATE:
05/31/2022
UNANNOUNCEDTIME BEGAN:
03:20 PM
MET WITH:Elizabeth MemoracionTIME COMPLETED:
04:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff engaged in a physical altercation with resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jaclyn Avila 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. LPA Avila ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical mask.

The Department has investigated the allegation and found the allegation to be substantiated. The Department reviewed relevant documentation to and conducted interviews with residents, and facility staff which revealed former Staff (S1) had been physically abusive with 2 residents. Resident 1 (R1) reported to both a doctor and nurse that S1 shoved R1 against the wall after S1 became frustrated with R1’s current medical condition. Resident 2 (R2) made a disclosure of physical abuse to family who reported it to the licensee in March of 2021. The licensee confronted S1 and the allegations were denied by S1. At the time the licensee learned of the allegations, the licensee failed to contact law enforcement or submit a report of suspected dependent adult/elder abuse until requested by Community Care Licensing February of 2022. At the time the Licensee learned of the abuse allegations made by R1, S1 had moved out of the facility and was no longer an employee.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
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-20220201115846
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: 05/31/2022
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
Again, at the time the licensee learned of the allegations, the licensee failed to contact law enforcement or submit a report of suspected dependent adult/elder abuse until requested by Community Care Licensing February of 2022.

Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 25-AS-20220201115846
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: 05/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2022
Section Cited
CCR
87468.2(a)(8)
1
2
3
4
5
6
7
87468.2(a)(8)-Personal Rights-To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agrees to remove staff from roster and is closing the facility. Licensee has provided clients and their responsible partys with eviction notices and they have moved from the facility. POC completed prior to findings.
8
9
10
11
12
13
14
Based upon interview and record review the Licensee failed to prevent physical abuse of 2 of 2 clients in care

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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3