030317773-9-7-2023-27-AS-KHOS-CVLRDW-20230912125639

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 030317773
Report Date: 09/07/2023
Date Signed: 09/07/2023 04:34:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2023 and conducted by Evaluator Christina Valerio

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230327083915

FACILITY NAME:	AMADOR RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	030317773
ADMINISTRATOR:	FLETA HERNDON		FACILITY TYPE:	740
ADDRESS:	155 PLACER DRIVE		TELEPHONE:	(209) 223-4444
CITY:	JACKSON	STATE: CA	ZIP CODE:	95642
CAPACITY:	49	CENSUS: 28	DATE:	09/07/2023
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Karly Sturgeon		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

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Facility staff are not feeding residents items that are on the menu.
Facility staff are not ensuring that residents receive adequate food.
Facility staff are not ensuring that residents receive showers according to schedule.
Facility staff are not keeping accurate resident records.
Facility staff are not meeting residents oral hygiene needs.
Facility staff are not ensuring that residents are adequately hydrated.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a complaint investigation. LPA met with Administrator Karly Sturgeon, and explained the purpose of the visit.

The Department has determined the following as it relates to the above aforementioned allegations. The investigation consisted of facility observations, interviews with residents, interviews with staff, and records review.

Facility staff are not feeding residents items that are on the menu.
LPA Valerio observed the facility on 03/30/23, 07/27/23, 08/01/2023, and 09/07/2023. Residents were served plated meals that composed of a protein, vegetable, starch, and drinks. According to the Reporting Party (RP), the facility served residents sacked lunches. During LPA's visits, LPA did not observe any meals served in a sacked paper bag.
Continued on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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 27-AS-20230327083915

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AMADOR RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 030317773
	VISIT DATE: 09/07/2023

NARRATIVE

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Continued from LIC 9099

LPA interviewed staff. S8 stated kitchen staff follow the menu. S7 stated the kitchen staff do not follow the menu a lot and is not aware of the reason. S7 stated there is only one kitchen staff during PM shift, which could be the reason. S7 is aware AM kitchen staff help PM kitchen staff, but believes there should be another kitchen staff to assist with ensure quality meals are being produced. S6 stated they try to follow the menu as best as they can; however, it depends on the food items received from the store.

Facility staff are not ensuring that residents receive adequate food.
According to staff interviews, S1 believes the facility could offer a better variety of food due to residents being tired of the same food, S2 does not believe the allegation is true, S3 did not comment on the food, S4 did not provide information on food, S5 personally believes the food could be better, S6 currently eats the meals that are served, S7 would not eat the food being served and does not believe they offer quality food, and S8 says the food is perfect. According to five (5) resident interviews, 3 residents rated the food as good, 1 resident stated the chicken is bland with no flavor, and 1 resident could not comment on the food. Technical Assistance was provided.

Facility staff are not ensuring that residents receive showers according to schedule

Based on interviews with staff, staff stated showers are almost always completed and marked in the shower log. If a resident refuses to shower, it is documented in the resident chart. PM staff reported that they are constantly busy and reported an extra staff member would help with getting task done. Based on LPA's observations, LPA did not observe the facility to have a foul odor in the common areas or inside inspected bedrooms. During LPA's interview with residents, LPA did not observe resident's to be in clothing with stains and did not observe greasy or unkempt hair. During LPA's visits, floor staff were often busy assisting with resident care.

Facility staff are not keeping accurate resident records.
LPA reviewed resident records. LPA did not observe any documents missing or not within compliance of Title 22 regulations. All files were updated annually. There were updated notes regarding appointments, dietary changes, and care plans that reflected current information.
Continues on LIC 9099 - C...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230327083915

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: AMADOR RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 030317773
	VISIT DATE: 09/07/2023

NARRATIVE

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Continued from LIC 9099 - C...

According to an interview with Administrator Karly, the facility keeps paper charts and electronic charts. If an employee forgets to chart on the electronic file, administrative staff can cross check the paper charts. Paper charts are used first and then transcribed to the electronic portion. Administrator Karly stated there are 2 charts for compliance and audit purposes.

According to RP, the staff fill in client charts even though a task was not completed. LPA could not find any information or observed any incidents to corroborate with the statement.

Facility staff are not meeting residents oral hygiene needs.

According to an interview with staff, there are only a few residents that need assistance with oral brushing. Staff will prompt residents to brush teeth or provided hand to hand assistance with brushing. LPA observed the facility ADL checklist log. Each resident has a personalized care plan for their needs. The care plan explains what the resident needs and how staff are to carry out the task. Once completed, the staff will mark if the resident has completed the task or staff assisted. Based on LPA review, there was not a time where staff did not sign off on oral hygiene. During LPAs interview with residents, LPA did not observe thrush inside the resident's mouth.

Facility staff are not ensuring that residents are adequately hydrated.
LPA Valerio observed the facility on 03/30/23, 07/27/23, 08/01/2023, and 09/07/2023. The visits revealed that the facility had a hydration station available for residents in care. Based on interviews with staff and LPA observation, activity staff prompt residents to drink water during snack pass in addition to caregivers assisting residents to drink the water. According to staff, the facility keeps track of fluid intake. The facility started to add fresh berries, cucumbers, or oranges to the water to increase water intake. Residents have reported that the water taste better with the addition of the fruit.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and a copy of report was left at the facility.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-823-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

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