045001608-12-19-2023-59-AS-KHOS-CZ7PA2-20240105100802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001608
Report Date: 12/19/2023
Date Signed: 12/19/2023 02:34:25 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/14/2023 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20231214101950

FACILITY NAME:	COUNTRY HEARTS		FACILITY NUMBER:	045001608
ADMINISTRATOR:	LEONARD, CAROL		FACILITY TYPE:	740
ADDRESS:	7170 LOWER WYANDOTTE RD.		TELEPHONE:	(530) 589-2466
CITY:	OROVILLE	STATE: CA	ZIP CODE:	95966
CAPACITY:	15	CENSUS: 3	DATE:	12/19/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Tamara Sproles - care staff		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident's glucose testing is not being logged properly. -UNSUBSTANTIATED
Staff did not know how to access resident's Medication Administration Record (MAR) - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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12/19/2023 12:00 PM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with Tamara Sproles care staff. Administrator Natasha Leonard. was notified by telephone that LPA had entered the facility to investigate a complaint.The purpose of this visit was to conduct a complaint investigation.

LPA reviewed glucose testing history and Medication Administration Record for 1 resident and interviewed one staff during the visit.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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 59-AS-20231214101950

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: COUNTRY HEARTS	FACILITY NUMBER: 045001608
	VISIT DATE: 12/19/2023

NARRATIVE

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Resident's glucose testing is not being logged properly - UNSUBSTANTIATED

Staff interview revealed that staff assists R1 with glucose testing but R1 gives themselves their insulin shots when needed. Staff have been trained on how to assist with glucose testing. R1 uses a Freestyle Libre 2 glucose monitor to test their insulin, the monitor logs a history of the glucose testing results. LPA reviewed the history on the monitor that went back at least two months. R1's glucose levels are checked at 6 :00 AM and in the evening. If the alarm sounds staff will test R1's glucose levels again. Staff stated they can share the glucose test history with R1's POA and health care provider if requested. This allegation is unsubstantiated.

Staff did not know how to access resident's Medication Administration Record (MAR) - UNSUBSTANTIATED

Staff 1 stated they sign in to the E-MAR on their phone using the Alchomy app, staff sign in and access all current medications for each resident and can update the date and time that a medication has been dispensed, the app allows staff to update the medication dispensing status of all residents. The Alchomy app has the ability to print the MAR if requested by R1's health care provider or POA. LPA reviewed R1's MAR in the Alchomy app and there was a complete MAR. This allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred, and the findings are UNSUBSTANTIATED.

An exit interview was conducted. A copy of the report was provided to administrator Natasha Leonard.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC9099 (FAS) - (06/04)

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