045001608-1-5-2024-59-AS-KHOS-CZBMSZ-20240109085246

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001608
Report Date: 01/05/2024
Date Signed: 01/05/2024 04:40:08 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
10/13/2023 and conducted by Evaluator Rebecca Knight

COMPLAINT CONTROL NUMBER: 59-AS-20231013114609

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: 2	DATE:	01/05/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Natasha Leonard - administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Administrator does not spend a sufficient amount of time at the facility. - UNSUBSTANTIATED
Staff is not providing requested medical records to resident's responsible party. – UNSUBSTANTIATED
Staff does not effectively communicate with resident's responsible party. . - UNSUBSTANTIATED

INVESTIGATION FINDINGS:

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01/05/2024 10:30 AM Licensing Program Analyst (LPA) Rebecca Knight, made an unannounced visit to the facility and met with administrator Natasha Leonard. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation the administrator was interviewed. LPA requested and reviewed the following documents: Staff list with telephone numbers, resident list, Advanced Health Care Directive, letter from responsible party for 1 resident, staffing schedules for the months of September and October 2023.

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: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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 59-AS-20231013114609

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: 01/05/2024

NARRATIVE

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Administrator does not spend a sufficient amount of time at the facility. - UNSUBSTANTIATED

LPA reviewed staffing schedules for the month of September and October 2023. Administrator worked an average of 4 day shifts and 1 to 2 night shifts per week. Administrator was on vacation for 5 consecutive days during the month of September 2023.

It was determined the administrator spends a sufficient amount of time at the facility. This allegation is unsubstantiated.

Staff is not providing requested medical records to resident's responsible party. - UNSUBSTANTIATED

LPA reviewed an Advanced Health Care Directive (Power of Attorney for Health Care) form which designates an agent to make health care decisions for R1. LPA reviewed a letter dated 09/01/2023 from R1’s responsible party (RP) requesting medical records from the facility.

Administrator stated they explained to R1’s RP that if they want medical records they need to contact Enloe Palliative Care. Administrator stated they do not have medical records for R1, Enloe Palliative Care has R1’s medical records. Administrator stated they gave R1’s RP the phone number for Enloe Palliative Care many times.

It was determined the responsible party has been advised to contact R1’s medical provider to obtain medical records. This allegation is unsubstantiated.

Continued on LIC9099-C

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Rebecca Knight	TELEPHONE: (530) 356-2841
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20231013114609

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: 01/05/2024

NARRATIVE

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Staff does not effectively communicate with resident's responsible party.

It was reported that R1’s RP has never been able to speak with the administrator.

Administrator stated they have called the RP multiple times and tried to have conversations and the RP told the administrator and the previous licensee that the RP can’t talk to them because the RP’s contract is with the placement company.

It was determined that the administrator has made reasonable efforts to communicate with R1’s RP. 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: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3