115002325-10-6-2022-25-AS-KHOS-CKJLAD-20221025083455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 115002325
Report Date: 10/06/2022
Date Signed: 10/06/2022 08:30:59 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
05/02/2022 and conducted by Evaluator Jaclyn Avila

COMPLAINT CONTROL NUMBER: 25-AS-20220502100735

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:	10/06/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Cyrena Reim, Staff Nicole Elder, Licensee		TIME COMPLETED:	09:00 PM

ALLEGATION(S):

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Administrator did not follow COVID-19 protocol
Staff not allowing residents to have visitors
Staff not allowing residents to participate in programs
Staff not allowing residents to leave the facility

INVESTIGATION FINDINGS:

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On 10/6/2022at approximately 3:15 PM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at the facility unannounced to provide findings regarding the allegations above. LPA met with Cyrena Reim, and explained the purpose of the visit. LPA spoke with License Nicole Elder via phone who stated she was out of the area and Cyrena could sign for the report. Nicole arrived prior to the completion of the visit and met with LPA. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

On 4/14/2022, the Department conducted an annual inspection at David Leroy Manor (6362 County Road 24, Orland). During the inspection the Department observed 5 of 5 clients at the facility. The Department inquired as to why the clients were not at day program. Licensee’s said, “Its closed due to COVID.” The Department completed the annual inspection.

Cont'd on 9099-C

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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 7

Control Number 25-AS-20220502100735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: DAVID LEROY MANOR	FACILITY NUMBER: 115002325
	VISIT DATE: 10/06/2022

NARRATIVE

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On 04/25/2022, the Department conducted an annual inspection at North Valley Services (NVS)-Adult Day Support Center (923 E. South St., Orland) and observed it to be open and operating. The Department inquired when the facility opened to in person services. The Department was told November of 2021. The Department inquired as to whether or not clients from David Leroy Manor where aware. The Department was told the licensee was not allowing the clients to come to program and not allowing Day Program Staff to go inside of the facility for in person support which made visits difficult due to weather. The Department was told that as of April 2022, the Licensee was now allowing mobile program.

On 5/2/2022, the Department received a complaint regarding the allegations above. The following are the findings:

NVS sent out a letter to all clients, Care Providers and Family Members dated March 24, 2021 regarding NVS Day Program Re-Opening Update and Communication. This letter in part states, “In Glenn County, our Orland Day Program is currently undergoing necessary facility maintenance, therefore we will continue to provide alternative services until project is complete.” This letter was signed and sent by NVS Director of Day Programs.

May 28th, 2021, NVS sent out a letter to all clients, Care Providers and Family Members regarding Orland Day Program Re-Opening Update and Communication. The letter in part states, “This letter is to inform you that our Orland Day Program is currently undergoing necessary facility maintenance. It is our sincerest hope that this interruption is brief. We would like to assure you all that every effort is being made to finalize facility maintenance as soon as possible. We will continue to provide some in person attendance to a very limited number of vocational workers. Remote and alternative services, as currently provided, will continue to the extent possible.” This letter was signed and sent by NVS Director of Day Programs.

August 2021, NVS returned to alternate services (packet delivery, phone calls and periodic outings), however David Leroy Manor did not participate. In November 2021, NVS began in person programming for all clients/consumers who wanted to participate. Per NVS, numerous calls went out to Licensee regarding clients at both David Leroy Facilities however Licensee Nicole Elder did not want clients to participate.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 25-AS-20220502100735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: DAVID LEROY MANOR	FACILITY NUMBER: 115002325
	VISIT DATE: 10/06/2022

NARRATIVE

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In March 2022, Licensee agreed to Mobile program (MP), but stipulated activities had to be outside and NVS had to provide their own table for the activity. April of 2022, NVS was able to begin MP however the weather and due to being required to remain outside created a barrier for MP to take place and was cancelled on occasion. An additional barrier due to day program staff not being allowed inside of the facility, it required they leave when they needed to use a restroom. During weeks that the weather made outside visits difficult, NVS continued to drop off packets for clients.

May 2022, Licensee Nicole Elder agreed to a tour NVS Day Program facility on June 1^st 2022 and clients began in person programming June 16^th 2022.

Clients interviewed shared they had not been to Day Programs in approximately 2 years due to “The COVID” although they have asked to return due to missing the social interaction and working. Clients interviewed shared they are not allowed to have indoor visitors although they’d like too and are not allowed to make calls or answer calls without permission. Clients expressed these are “Nicole and Bob’s rules” and are meant to protect them. Clients expressed getting in “trouble or restricted” if they broke the rules. Clients expressed their “love” for Nicole and referred to Nicole as a second “mother.”

Licensee stated the house rules are simple and are the same for both facilities: David Leroy Manor and David Leroy Manor II. Licensee said clients don’t have visitors because they don’t have anyone to visit. Licensee said there were no rules about the phone however they do try to redirect clients if the call will escalate them or if there are others in the area of the phone. Licensee said she requested NVS Day Program Manager to stop telling clients they were opening because of the delays or barriers day program was facing. Licensee said day program did open up in November 2021 but wasn’t open to David Leroy Manor (II) clients.

Day program staff interviewed expressed concern for the restrictions placed on Clients from David Leroy Manor (II) by their licensee. Day Program staff interviewed stated licensees at other licensed residential homes allowed staff to come indoor to engage with clients and allowed Program to take clients on outings. Day program staff interviewed stated that the David Leroy Manor staff did not allow them to speak or interact with clients when dropping off packets prior to mobile program.

Cont'd on LIC 9099-C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 25-AS-20220502100735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: DAVID LEROY MANOR	FACILITY NUMBER: 115002325
	VISIT DATE: 10/06/2022

NARRATIVE

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Community Care Licensing has never restricted clients on leaving their licensed care homes or prohibited clients from attending Day Program. Due to COVID 19 pandemic a visitation waiver was put into place however it was lifted February 2022 allowing indoor visitation regardless of vaccination status.

On 10/6/2022, this Department observed a no visitor sign outside the main entrance. An additional sign stated Staff Entrance Only. Staff on duty said visitors were allowed to visit outside but not indoors due to safety protocols related to COVID. Client present confirmed that was the rule. After staff made a call to Licensee staff said indoor visitors were allowed.

Based on the Department's observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D. Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 25-AS-20220502100735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: DAVID LEROY MANOR	FACILITY NUMBER: 115002325
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/07/2022 Section Cited CCR 85079(c)	1 2 3 4 5 6 7	85079 Activities (c) The licensee shall ensure that clients are given the opportunity to attend and participate in community activities This requirement is not met as evidenced by: Based upon observation, interview and document review	1 2 3 4 5 6 7	Licensee has already corrected the deficiency and is currently working with Program to ensure clients are able to participate when they choose to.
	8 9 10 11 12 13 14	The Licensee failed to ensure 5 of 5 clients were given the opportunity to participate in program. This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.	8 9 10 11 12 13 14
Type A 10/07/2022 Section Cited CCR 85087.3(a)	1 2 3 4 5 6 7	85087.3 Indoor Activity Space (a) As a condition of licensure, there shall be common rooms, including a living room, dining room, den or other recreation/activity room, which provide the necessary space and/or separation to promote and facilitate the program of planned activities specified in Section 85079	1 2 3 4 5 6 7	Licensee agrees to facilitate day program staff to conduct indoor activities. Licensee will provide a letter of understanding to CCL by COB 10/7/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based upon observation, interview and document review The Licensee failed to ensure 5 of 5 clients were given indoor space to participate in program. This poses an immediate Health, Safety and/or Personal Rights risk to clients 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: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 25-AS-20220502100735

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: DAVID LEROY MANOR	FACILITY NUMBER: 115002325
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/07/2022 Section Cited CCR 85072(4)	1 2 3 4 5 6 7	85072 Personal Rights (4) To have visitors, including advocacy representatives, visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients. This requirement is not met as evidenced by: Based upon observation, interview and document review	1 2 3 4 5 6 7	Licensee agrees to remove the no visitation signs and meet with staff and clients to ensure they are aware that indoor visitors are allowed. Sign in sheet for staff will be provided no later than COB on 10/7/2022
	8 9 10 11 12 13 14	The Licensee failed to ensure 5 of 5 clients were given the opportunity to have visitors as required by regulation. This poses an immediate Health, Safety and/or Personal Rights risk to clients 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: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
05/02/2022 and conducted by Evaluator Jaclyn Avila

COMPLAINT CONTROL NUMBER: 25-AS-20220502100735

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:	10/06/2022
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Cyrena Reim, Staff Nicole Elder, Licensee		TIME COMPLETED:	09:00 PM

ALLEGATION(S):

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Staff not allowing residents to have private telephone calls

INVESTIGATION FINDINGS:

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

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 341-4932
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022

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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