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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 115002409
Report Date: 10/06/2022
Date Signed: 10/06/2022 08:25:02 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-20220502120108
FACILITY NAME:DAVID LEROY MANOR IIFACILITY NUMBER:
115002409
ADMINISTRATOR:NICOLE ELDERFACILITY TYPE:
735
ADDRESS:900 FIFTH STTELEPHONE:
(530) 356-5011
CITY:ORLANDSTATE: CAZIP CODE:
95963
CAPACITY:6CENSUS: 6DATE:
10/06/2022
UNANNOUNCEDTIME 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 have private telephone calls
Staff not allowing residents to participate in programs
Staff not allowing residents to leave the facility
INVESTIGATION FINDINGS:
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On 10/6/2022/2022 at approximately 3:15 PM, Licensing Program Analyst (LPA) Jaclyn Avila arrived at sister facility (David Leroy Manor 6362 COUNTY ROAD 24, Orland) unannounced to provide findings regarding the allegations above. LPA met with Cyrena Reim, and explained the purpose of the visit. LPA spoke with Licensee Nicole Elder via phone who stated she was out of the area and Cyrena could sign for the report. Nicole arrived later and was able to go over findings. 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 said, “Its closed due to COVID.” The Department completed the annual inspection.

Cont'd on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
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 6
Control Number 25-AS-20220502120108
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 II
FACILITY NUMBER: 115002409
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 were 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 28, 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 due to concern related to COVID.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
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 6
Control Number 25-AS-20220502120108
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 II
FACILITY NUMBER: 115002409
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 due to concerns related to COVID. 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 1st 2022 and clients began in person programming June 16th 2022.

The Department observed on May 11th, 2022 the front door of the facility to have a sign up that said “No Visitors Allowed." An additional sign on the front door stated “No Public Entrance!! Staff Entrance only. Mask Zone only!!” The Department observed 5 of 6 clients to be home. At the time of visit the Department observed and addressed immediate health and safety concerns (Refer to LIC 809 on 5/11/22). Staff present was unaware that facilities were required to allow visitors and day programs were open. The clients stated they haven't gone to day program since COVID.

On 09/17/2022, during an additional site visit the Department observed the “No Public Entrance!! Staff Entrance only. Mask Zone only!!” to still be up.

Staff interviewed confirmed Licensee Nicole Elder is who communicates with the Day Program and who keeps staff aware of CCLD guidance. Staff stated staff was unaware that at time of the site visit in May, Day Program was operating, and that indoor visitation was allowed. The Department provided staff with PIN 22-07 regarding visitation opening up February 2022.

The Department observed the phone to be corded and on the kitchen bar. Interviews revealed that if a client wants privacy, they could wait to use the phone or utilize the pantry/med room. Interviews with clients revealed they are not afforded privacy when on the phone. Clients expressed that they either did not know the rules about the phone or that they had to ask to use it.

Cont'd on LIC 9099-C
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
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 6
Control Number 25-AS-20220502120108
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 II
FACILITY NUMBER: 115002409
VISIT DATE: 10/06/2022
NARRATIVE
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Clients interviewed stated there were 2-3 years they weren’t allowed to go to Day Program. Clients interviewed stated Nicole and Bob told them “State” didn’t want them to go due to COVID although they expressed wanting to return to program.

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.

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.

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.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
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 6
Control Number 25-AS-20220502120108
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 II
FACILITY NUMBER: 115002409
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)
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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
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Licensee has already corrected the deficiency and is currently working with Program to ensure clients are able to participate when they choose to.
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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.
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Type A
10/07/2022
Section Cited
CCR
85087.3(a)
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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
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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.
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This requirement is not met as evidenced by: Based upon observation, interview and document review The Licensee failed to ensure 6 of 6 clients were given indoor space to participate in program.

This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
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 6
Control Number 25-AS-20220502120108
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 II
FACILITY NUMBER: 115002409
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)
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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
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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
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The Licensee failed to ensure 6 of 6 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.
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Type A
10/07/2022
Section Cited
CCR
85072(9)
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85072 Personal Rights(9) To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies.
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Licensee agrees to meet with clients and get their input on what privacy they would like and their understanding of privacy. Licensee will provide CCLD with the outcome of the converstion by COB on 10/07/2022
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The Licensee failed to ensure 6 of 6 clients are given privacy during phone calls.

This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Jaclyn Avila
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 6