236803358-3-17-2021-21-AS-KMOA-BZFTU8-20210325150156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 236803358
Report Date: 03/17/2021
Date Signed: 03/17/2021 04:34:30 PM

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
12/28/2020 and conducted by Evaluator Christopher Arnhold

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201228123844

FACILITY NAME:	HOLY SPIRIT RESIDENTIAL CARE HOME INC. II		FACILITY NUMBER:	236803358
ADMINISTRATOR:	GONZALEZ, PERLA		FACILITY TYPE:	740
ADDRESS:	1275 ELM STREET		TELEPHONE:	(707) 972-5831
CITY:	UKIAH	STATE: CA	ZIP CODE:	95482
CAPACITY:	6	CENSUS: 6	DATE:	03/17/2021
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Perla Gonzalez		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident's diapering needs were not met while in care.

Staff did not seek timely medical attention for resident in care.

INVESTIGATION FINDINGS:

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At approximately 4:15PM, Licensing Program Analyst (LPA) Chris Arnhold contacted Perla Gonzalez to deliver investigative findings for the above allegations. This visit is being conducted by telephone due to Covid-19 precautions. Based on a review of records and interviews conducted, the allegations listed above are Unfounded. Resident was sent to ER on 12/23/2020, for diarrhea, sore throat and low O2 levels. Resident was returned to facility the same day with COVID-19 diagnosis. Resident was sent to the ER again on 12/26/2020 for severe diarrhea, not eating or drinking, weakness, sore throat and low O2 levels. Based on witness statements, resident suffered from severe diarrhea while being transported to ER and their skin condition was good and showed no signs of redness or injury. Since the facility sent resident to the ER twice in a 3 day period and resident was returned, the facility did, in fact, seek timely medical attention for resident in care.
Continued on LIC9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021

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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Control Number 21-AS-20201228123844

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: HOLY SPIRIT RESIDENTIAL CARE HOME INC. II	FACILITY NUMBER: 236803358
	VISIT DATE: 03/17/2021

NARRATIVE

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LPA reviewed resident files and found no evidence of skin breakdown or other health concerns not being met. The needs and service plans are detailed and have input from responsible parties.

This agency has investigated the above allegations. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No citations issued.

Original signature on file.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021

LIC9099 (FAS) - (06/04)

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