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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 126803492
Report Date: 11/03/2020
Date Signed: 11/06/2020 09:47:30 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/30/2020 and conducted by Evaluator Christopher Arnhold
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200430154322
FACILITY NAME:CLEO'S HOMEFACILITY NUMBER:
126803492
ADMINISTRATOR:HANRAHAN-GEE, LEAHFACILITY TYPE:
740
ADDRESS:129 HIGGINS STREETTELEPHONE:
(707) 382-2697
CITY:EUREKASTATE: CAZIP CODE:
95501
CAPACITY:15CENSUS: 11DATE:
11/03/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Leah GeeTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff did not administer resident's medication as prescribed.
INVESTIGATION FINDINGS:
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At approximately 02:40PM, Licensing Program Analyst (LPA) Chris Arnhold made contact with Administrator Leah Gee, via telephone, to deliver findings to the above allegation. This visit is being conducted by telephone due to COVID-19 precautions. Based on interviews conducted and a review of records, facility staff did not administer medication as prescribed. Medication was given twice daily at the same time every day. Physician direction was for every 6 hours as needed. The documentation also showed more medication was administered than the amount in the bottle. There is no documentation to show an additional supply was aquired. A meeting with Licensee and CCL will be scheduled in the future to address this medication documentation error.
Based on LPA’s observations, interviews conducted and a review of records, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
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 3
Control Number 21-AS-20200430154322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: CLEO'S HOME
FACILITY NUMBER: 126803492
VISIT DATE: 11/03/2020
NARRATIVE
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Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Administrator and Appeal rights were given.

Original signature on file.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20200430154322
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CLEO'S HOME
FACILITY NUMBER: 126803492
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2020
Section Cited
CCR
87465(a)(5)
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87465(a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement was not met as evidenced by: Based on
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Licensee to ensure medication is administered per Physician orders. Licensee to conduct training with all staff on following physician orders and documentation. Training was conducted May 5-8, 2020.
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records review, Licensee did not administer medication as prescribed by Physician in 1 of 11 residents. This poses an immediate health risk to residents in care.
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Training materials and signed staff rosters of completed training to be submitted to CCL by POC date of 11/20/2020.
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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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher ArnholdTELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020
LIC9099 (FAS) - (06/04)
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