312700022-3-9-2022-25-AS-LMUZ-CDPV6H-20220421160933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700022
Report Date: 03/09/2022
Date Signed: 03/09/2022 09:34:12 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/07/2021 and conducted by Evaluator DeAnna Williams-Lyons

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211207144615

FACILITY NAME:	GRACE GARDEN HOME CARE		FACILITY NUMBER:	312700022
ADMINISTRATOR:	BOT, MARY		FACILITY TYPE:	740
ADDRESS:	6410 WISP COURT		TELEPHONE:	(916) 781-9177
CITY:	ROCKLIN	STATE: CA	ZIP CODE:	95765
CAPACITY:	6	CENSUS: 5	DATE:	03/09/2022
		UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Mary Bot ,Administrator		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights:
Staff lifting resident improperly.

Personal Rights:
Staff verbal abuse to resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On March 9, 2022, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived unannounced to deliver findings for Complaint # 25-AS-.20211207144615. LPA met with Mary Bot, Licensee and explained the purpose of the visit. Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of g COVID-19 infection to affirm no COVID-19 related symptoms and completed a facility risk assessment. LPA ensured she applied hand sanitizer before entering the facility and a N-95 mask was worn for Personal Protective Equipment..

During the investigation, LPA interviewed 4 residents and 4 facility staff. LPA obtained and reviewed the following documents: Admission Agreements, Physician’s Reports, Bill of Rights, Dec 2021 Staffing Schedule, Staff Roster, and Resident Roster.

To continue see 9099 -C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

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 2

Control Number 25-AS-20211207144615

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: GRACE GARDEN HOME CARE	FACILITY NUMBER: 312700022
	VISIT DATE: 03/09/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Facility staff lifted resident improperly and staff verbally abused resident.

On 2/24/2022, LPA conducted interviews regarding the allegations listed above. During staff interviews, 4 of 4 staff stated they had never verbally abused a resident. During resident interviews 4 of 4 residents stated that staff treats them with dignity.

It was also alleged facility staff improperly lifted resident. Residents stated in interviews that staff do not injure them during lifts or transfers. All residents stated that staff have never lifted them improperly during transfers. The Licensee/Administrator conducted an internal investigation and found no information which suggests facility staff lifted resident improperly and staff verbally abused resident. LPA was unable to interview the accused staff due to no contact information available. LPA was also unable to interview hospice aid worker after multiple attempts to contact.

Based on information gathered, the allegations that facility staff lifted resident improperly and staff verbally abused resident are UNSUBSTANTIATED, meaning, although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the above allegations did or did not occur.

Per California Code of Regulations, Title 22, no deficiencies were cited regarding the above allegations.

Exit interview was conducted and a copy of this report was given to Mary Bot.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2