115002325-5-23-2024-59-AS-KHOS-D64R5C-20240610124253

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 115002325
Report Date: 05/23/2024
Date Signed: 05/23/2024 08:22:24 AM

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
03/21/2024 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20240321142618

FACILITY NAME:	DAVID LEROY MANOR		FACILITY NUMBER:	115002325
ADMINISTRATOR:	ELDER, NICOLE		FACILITY TYPE:	735
ADDRESS:	6362 COUNTY ROAD 24		TELEPHONE:	(530) 865-7448
CITY:	ORLAND	STATE: CA	ZIP CODE:	95963
CAPACITY:	6	CENSUS: 5	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	08:14 AM
MET WITH:	Adminstrator- Nicole Elder		TIME COMPLETED:	08:35 AM

ALLEGATION(S):

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Facility not providing food choices to residents.
Facility not assisting in finding medical treatment options for residents.
Facility staff verbally abusive towards residents.

INVESTIGATION FINDINGS:

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On 05/23/2024 Licensing Program Analyst Jaynae Boyles made an unannounced visit to the facility and met with administrator. The purpose of this visit was to deliver the results of a complaint investigation.

During the course of the investigation the administrator and six residents were interviewed. LPA reviewed the following: Menu for two weeks, observed the freezer, fridge, and dry food storage. The facility appears to have a sufficient amount of food.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20240321142618

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: DAVID LEROY MANOR	FACILITY NUMBER: 115002325
	VISIT DATE: 05/23/2024

NARRATIVE

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LPA investigated, “Facility not providing food choices to residents.” It was reported that some of the residents do not feel that they received a choice for meals; and that there was little to no input from them. However, overall, it was stated that the residents were fine with the meal choices and that the administrator has changed the process in that the residents are more involved with the menu and creating lunches when leaving the facility for the day program.

LPA investigated, “Facility not assisting in finding medical treatment options for residents.” It was reported that a resident (Resident 1) indicated that there was a delay in medical insurance changing to the new county of origin, which created a delay in medical and dental care. However, the resident did not have any pressing medical or dental needs. The resident received a completed medical physical before placement at the facility. While there was a delay in medical care this was not the fault of the facility, rather the insurance.

LPA investigated, “Facility staff verbally abusive towards residents.” It was reported that a resident (Resident 1) indicated that a texting exchange between R1 and the administrator occurred. The resident reported that she felt upset and her feelings were hurt when this interaction occurred. All other residents at the facility stated to the LPA that they feel safe at the facility and believe the staff to be kind to them.

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.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Jaynae Boyles
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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