312700808-8-31-2021-25-AS-KHOS-C6MR4K-20210907124141

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700808
Report Date: 08/31/2021
Date Signed: 08/31/2021 03:13:58 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
06/04/2021 and conducted by Evaluator Konnor Leitzell

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210604114111

FACILITY NAME:	PACIFIC COAST CARE HOMES		FACILITY NUMBER:	312700808
ADMINISTRATOR:	ZAIDI, MARIA		FACILITY TYPE:	740
ADDRESS:	4470 ROLLING OAKS DRIVE		TELEPHONE:	(916) 823-3902
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	6	CENSUS: 3	DATE:	08/31/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Nited (Denisse) Perea (Administrator)		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident's care needs not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 8/31/2021 to deliver findings for a complaint Community Care Licensing (CCL) received on 6/4/2021 which alleged that “Resident's care needs not being met”. LPA met with Nited (Denisse) Perea (Administrator) and explained the purpose of the visit. Prior to entering, 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. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff and answers were documented in their visitor screening log.

CONT LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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 4

Control Number 25-AS-20210604114111

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: PACIFIC COAST CARE HOMES	FACILITY NUMBER: 312700808
	VISIT DATE: 08/31/2021

NARRATIVE

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Throughout the course of the investigation, CCL conducted interviews, toured facility, and reviewed documents. Interviews were conducted with Staff, Administrator, Residents and R1’s Responsible Party (RP). When receiving the complaint, CCL was informed resident calls out for help and no one assist, and that their incontinence care needs are not being met. Through interviews conducted, it was stated R1 would be routinely checked on roughly every twenty (20) minutes, as all residents are. It was also stated when R1 would call out for help, staff would assist R1 with their needs if not immediately, then within five (5) minutes. Interviews with resident’s stated the care staff treat them well, going on to state staff provide good care to facility residents.

LPA noted when reviewing document, R1 did have incontinence care needs along with other ADL’s that were to be performed by the facility. Documents provided indicate R1 had Home Health come in as well to assist with physical therapy.

When at facility conducting facility tours, LPA Leitzell noted care staff continuously monitoring residents and assisting residents with their care needs. LPA failed to see any residents go unattended or neglected during facility visits.

Through interviews conducted, documents reviewed, and facility visits performed; CCL finds the allegation of Resident’s Care Needs Not Being Met to be UNSUBSTANTIATED. A finding that the allegation 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. There are no deficiencies being cited per Title 22 Regulations, Division 6, Chapter 8. Exit interview conducted. A copy of this report was left at facility for review.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

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
06/04/2021 and conducted by Evaluator Konnor Leitzell

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210604114111

FACILITY NAME:	PACIFIC COAST CARE HOMES		FACILITY NUMBER:	312700808
ADMINISTRATOR:	ZAIDI, MARIA		FACILITY TYPE:	740
ADDRESS:	4470 ROLLING OAKS DRIVE		TELEPHONE:	(916) 823-3902
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	6	CENSUS: 3	DATE:	08/31/2021
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Nited (Denisse) Perea (Administrator)		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Licensee not responding promptly to authorized representative request.
Resident not provided access to phone calls.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Konnor Leitzell arrived at the facility unannounced on 8/31/2021 to deliver findings for a complaint Community Care Licensing (CCL) received on 6/4/2021 which alleged that “Licensee not responding promptly to authorized representative request” and “Resident not provided access to phone calls”. LPA met with Nited (Denisse) Perea (Administrator) and explained the purpose of the visit. Prior to entering, 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks. Additionally, LPA was screened by staff and answers were documented in their visitor screening log.

CONT LIC9099C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20210604114111

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: PACIFIC COAST CARE HOMES	FACILITY NUMBER: 312700808
	VISIT DATE: 08/31/2021

NARRATIVE

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Through the course of the investigation, CCL conducted interviews, toured facility, and reviewed documents. Interviews were conducted with Staff, Administrator, Residents and R1’s Responsible Party (RP). When receiving complaint, it was stated admin takes days to respond to phone calls; and the request to provide transfer documents had not been provided. Through reviewing documents provided, CCL was able to determine that Admin provided transfer documents to future facility on the same day as written request was provided via text. In addition, documents provided indicated admin did not forgo any messages from R1’s RP, and conducted a total of three (3) successful phone calls between 5/17 and 6/4. Interviews conducted with admin further indicated facility complied with resident’s POA’s requests, and did so in a timely manner.

During interview conducted with staff regarding residents accessibility to the home telephone, CCL was informed that the facility has a cordless telephone that is used often by residents. Staff informed CCL that when resident’s receive a phone call, staff will answer and provide the resident with the phone. Staff indicated they assist with telephone calls when needed, but gives resident’s privacy. Further interviews indicated when residents request to make a call, and the phone is available they provide it to them, assisting with dialing the numbers occasionally.

Based on information obtained, CCL finds the above allegation to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report was left at facility for review.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor Leitzell	TELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC9099 (FAS) - (06/04)

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