107206924-3-9-2021-24-AS-SPIY-BZ5PJW-20210315112213

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206924
Report Date: 03/05/2021
Date Signed: 03/09/2021 03:48:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2021 and conducted by Evaluator Lady Cabrera

COMPLAINT CONTROL NUMBER: 24-AS-20210122081101

FACILITY NAME:	SHAEMAR RESIDENTIAL CARE II		FACILITY NUMBER:	107206924
ADMINISTRATOR:	RONALD & MARCELIA WORTHLEY		FACILITY TYPE:	740
ADDRESS:	6123 N. 10TH STREET		TELEPHONE:	(559) 451-0108
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS: 2	DATE:	03/05/2021
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Wilma Worthley, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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2
3
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5
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7
8
9

Resident sustained a burn while in care

INVESTIGATION FINDINGS:

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5
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7
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10
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12
13

Licensing Program Analyst (LPA) Lady Cabrera conducted the subsequent complaint investigation inspection to the facility to deliver complaint findings.

During the course of the investigation Licensing Program Analyst (LPA) Lady Cabrera interviewed staff, obtained, and reviewed facility records. It was determined based on the interviews and records review that the above allegation is SUBSTANTIATED. On 11/26/2020, Resident sustained a burn while in care from a heating pad.

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. Health and Safety Code §1569.312(e), is being cited on the attached LIC 9099D.

An exit interview was conducted with the Licensee. A copy of this report, LIC 9099-D and appeal rights were provided. The Licensee's signature on this form acknowledges receipt of these documents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

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 24-AS-20210122081101

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: SHAEMAR RESIDENTIAL CARE II	FACILITY NUMBER: 107206924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/19/2021 Section Cited HSC 1569.312(e)	1 2 3 4 5 6 7	§1569.312 Every facility required to be licensed under this chapter shall provide at least the following basic services: (e)Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall develop a plan of correction (POC):procedure and/or policy to ensure that all staff monitor the activities of the residents while they are under the supervision of facility to ensure their general health, safety, and well-being by 03/19/2021.
	8 9 10 11 12 13 14	Based on records review, observation and interview, the Licensee did not ensure to monitor the resident, who got a second degree burn from a heating pad, which poses an Immediate Health and Safety risk to persons 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: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2021 and conducted by Evaluator Lady Cabrera

COMPLAINT CONTROL NUMBER: 24-AS-20210122081101

FACILITY NAME:	SHAEMAR RESIDENTIAL CARE II		FACILITY NUMBER:	107206924
ADMINISTRATOR:	RONALD & MARCELIA WORTHLEY		FACILITY TYPE:	740
ADDRESS:	6123 N. 10TH STREET		TELEPHONE:	(559) 451-0108
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS: 2	DATE:	03/05/2021
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Wilma Worthley, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not seek resident timely medical attention
Staff did not inform POA of change in resident's medical condition

INVESTIGATION FINDINGS:

1
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3
4
5
6
7
8
9
10
11
12
13

During this visit LPA delivered investigation findings regarding the above allegations.The Department has investigated the complaint alleging: Staff did not seek resident timely medical attention and Staff did not inform POA of change in resident's medical condition.

On 11/26/2020, Administrator contacted the doctor regarding Resident's (R1) medical condition. On 11/27/2020, R1 was treated by the doctor at the facility. Based on records review and interviews the facility did seek timely medical attention and facility had often communication with R1’s Power of Attorney (POA) regarding her medical condition.

Based on the interviews conducted and/or records review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted with the Licensee. The Licensee's signature on this form acknowledges receipt of this document.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2021 and conducted by Evaluator Lady Cabrera

COMPLAINT CONTROL NUMBER: 24-AS-20210122081101

FACILITY NAME:	SHAEMAR RESIDENTIAL CARE II		FACILITY NUMBER:	107206924
ADMINISTRATOR:	RONALD & MARCELIA WORTHLEY		FACILITY TYPE:	740
ADDRESS:	6123 N. 10TH STREET		TELEPHONE:	(559) 451-0108
CITY:	FRESNO	STATE: CA	ZIP CODE:	93710
CAPACITY:	6	CENSUS: 2	DATE:	03/05/2021
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Wilma Worthley, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mishandled resident's paperwork

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Lady Cabrera conducted the subsequent complaint investigation inspection to the facility to deliver complaint findings.

Per staff and third-party interviews, it was discovered that all parties interviewed with regards to this allegation (Staff mishandled resident's paperwork) gave statements that assert the opposite version of occurred events resulting in the provided statements being in conflict with each other. Based on the information obtained from the records and conducted interviews, it was not possible to determine that these allegations had occurred as specified in the complaint. Therefore, the allegations are INCONCLUSIVE.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Lady Cabrera	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

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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