312700641-3-16-2022-25-AS-APEZ-CCMTL9-20220318144908

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700641
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:51:40 PM

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
10/29/2021 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20211029094754

FACILITY NAME:	SOMERFORD PLACE-ROSEVILLE		FACILITY NUMBER:	312700641
ADMINISTRATOR:	TAYLOR, DEBORAH		FACILITY TYPE:	740
ADDRESS:	110 STERLING COURT		TELEPHONE:	(617) 796-8350
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	64	CENSUS: 38	DATE:	03/16/2022
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Jane Scaparro- Executive Director		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff spoke inappropriate to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 3/16/2022 to deliver complaint findings. LPA met with Executive Director, Jane Scaparro, and explained the purpose of the visit. 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 and LPA completed a facility risk assessment at the facility. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA were screened by facility staff upon entering the facility.

Allegation: Staff spoke inappropriate to resident in care. – Unsubstantiated.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents such as staff roster, resident roster, Resident’s Physicians Report (R1), Admission Agreement, Identification and Emergency Information, Level of Care Assessment, and Grievance/Concern Report relevant to the allegation listed above.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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 25-AS-20211029094754

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: SOMERFORD PLACE-ROSEVILLE	FACILITY NUMBER: 312700641
	VISIT DATE: 03/16/2022

NARRATIVE

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The facility had submitted relevant party’s Grievance/ Concern report to CCL for review. According to the Grievance/ Concern report, R1 was on a video chat call with family when R1’s son heard caregiver state that an incontinence issue was “nasty.” Resident Care Director, Snehal Lata, had conducted internal investigation. It was discovered, the two caregivers that assisted R1 on 10/16/2022 were agency staff from Allure Care Agency. Resident Care Director had questioned the agency caregivers which both denied anything was ever said to R1. Resident Care Director stated the facility is no longer using Allure Care Agency and any new agency care staff will go through in-service training on dementia residents on their first day assisting at the community.

Interview statement received from Allure Care Agency Manager indicated that the company conducted an internal investigation and resolved the issue by not sending S2 to assist residents at Somerford Place. Allure Care Agency Caregiver (S1) denied speaking inappropriately to R1.

LPA finds the allegation to be UNSUBSTANTIATED, meaning 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, and the findings are unsubstantiated.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC9099 (FAS) - (06/04)

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