097001145-6-9-2021-27-AS-MSEY-C42SBR-20210616134423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 097001145
Report Date: 06/09/2021
Date Signed: 06/09/2021 01:01:57 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
11/05/2020 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 27-AS-20201105091127

FACILITY NAME:	APPLE COUNTRY CARE HOME # 2		FACILITY NUMBER:	097001145
ADMINISTRATOR:	LAURA FOSS		FACILITY TYPE:	740
ADDRESS:	6245 EL DORADO STREET		TELEPHONE:	(530) 622-3033
CITY:	EL DORADO	STATE: CA	ZIP CODE:	95623
CAPACITY:	6	CENSUS: 0	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Rick Heider		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff yelled at resident

Staff spoke inappropriately to resident

Facility fence is in disrepair

INVESTIGATION FINDINGS:

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Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore an N-95 respirator and maintained distance during the visit. LPA Smith and Wolter conducted an unannounced complaint visit and met with Rick Heider. Allegations:

Facility fence is in disrepair
Fence portion approximately 8 feet in length is not secured and is leaning on a more secure portion of the fence. Other portions of the fence are completely missing slates. According to the licensee, a recent storm blew the fence down. Photos were taken Based on this, the allegation is SUBSTANTIATED.

See 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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 4

Control Number 27-AS-20201105091127

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: APPLE COUNTRY CARE HOME # 2	FACILITY NUMBER: 097001145
	VISIT DATE: 06/09/2021

NARRATIVE

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Staff yelled at resident & Staff spoke inappropriately to resident

Direct witness stated on several occasions, a staff member was being verbally abusive to the residents in care. Staff was heard belittling residents in care by saying "Are you stupid? This is your f***ing food, this is the table, food, table, food. Eat your food." along with loud banging. On another occasion, loud screaming was heard "You're not going anywhere, put your feet up, now". On both occasions crying was heard from residents. Based on direct witness statement these allegations are SUBSTANTIATED.

As a result of this investigation, LPA finds the allegations that staff yelled at resident, staff spoke inappropriately to resident and facility fence is in disrepair to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 27-AS-20201105091127

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: APPLE COUNTRY CARE HOME # 2	FACILITY NUMBER: 097001145
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/09/2021 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities-To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on direct witness interviews, facility staff was heard yelling at residents in care and is in violation of this section.	1 2 3 4 5 6 7	All facility staff shall take a personal rights course. This shall be done within 5 days. Licensee shall forward completed certificates / documents of all staff to LPA, to clear this deficiency. *Deficiency cleared during visit. No staff are currently working*
	8 9 10 11 12 13 14	This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 06/09/2021 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities-To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	All facility staff shall take a personal rights course. This shall be done within 5 days. Licensee shall forward completed certificates / documents of all staff to LPA, to clear this deficiency. *Deficiency cleared during visit. No staff are currently working*
	8 9 10 11 12 13 14	Based on direct witness interviews, facility staff was cursing at residents and slamming doors in the facility This is in violation of this section. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14

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 Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 27-AS-20201105091127

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: APPLE COUNTRY CARE HOME # 2	FACILITY NUMBER: 097001145
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/09/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303-Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Facility shall repair fence. This shall be done within 15 days. LPA will revisit facility to observe that the repairs were completed. Facility fence has been repaired. *Deficiency cleared during visit*
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on direct observation, facility fence was observed to be in disrepair with section loose or missing. Based on this, licensee is in violation of this section. This poses a potential health and safety risk to residents 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 Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

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