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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312700277
Report Date: 08/09/2022
Date Signed: 08/09/2022 04:40:41 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, 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
05/04/2022 and conducted by Evaluator Kevin Mknelly
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220504122945
FACILITY NAME:COMPASSION CAREFACILITY NUMBER:
312700277
ADMINISTRATOR:MARIUT, ANAFACILITY TYPE:
740
ADDRESS:409 YALE DRIVETELEPHONE:
(916) 666-7297
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 6DATE:
08/09/2022
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:CaregiverTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Facility staff caused injury to resident
Facility staff removed resident’s phone
Facility staff failed to safeguard resident belongings
INVESTIGATION FINDINGS:
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On 8/9/22 , Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with clinical staff. Prior to initiating the complaint 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. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened for Covid 19 symptoms at the facility.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.
R1, who is diagnosed with dementia was unable to provide reliable historical information regarding her phone, belonging or injuries that could be corroborated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
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-20220504122945
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: COMPASSION CARE
FACILITY NUMBER: 312700277
VISIT DATE: 08/09/2022
NARRATIVE
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Residents and facility staff were interviewed and no injuries were witnessed that were the result of a lack of supervision or mistreatment of R1.

Reports from family members were at time contradictory of each other regarding R1’s phone and other belongings whereabouts.

R1’s records indicate that all injuries were properly reported to R’s physician and power of attorney.


As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with caregiver.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin MknellyTELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2