312700943-6-28-2022-25-AS-KHOS-CGJHDG-20220721060619

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700943
Report Date: 06/28/2022
Date Signed: 06/28/2022 01:13:03 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
01/06/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20220106130932

FACILITY NAME:	A LOVING SENIOR CARE HOME II		FACILITY NUMBER:	312700943
ADMINISTRATOR:	RAMOS, QUEENIE R.		FACILITY TYPE:	740
ADDRESS:	1190 EARLTON LN.		TELEPHONE:	(510) 427-5165
CITY:	LINCOLN	STATE: CA	ZIP CODE:	95648
CAPACITY:	6	CENSUS: 4	DATE:	06/28/2022
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Queenie R Ramos, Administrator		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff is having relationship with resident.

INVESTIGATION FINDINGS:

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On 6/28/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Queenie Ramos, to conclude a complaint investigation into the allegation listed above. LPA wore an N-95 mask and was screened by facility upon entry.

During the investigation, the Department toured the facility, conducted interviews, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff is having relationship with resident

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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 3

Control Number 25-AS-20220106130932

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: A LOVING SENIOR CARE HOME II	FACILITY NUMBER: 312700943
	VISIT DATE: 06/28/2022

NARRATIVE

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Interview with resident (R1) conducted on 1/13/2022 indicated that R1 was romantically interested in staff member (S1), but did not initiate or act on any romantic feelings towards S1. Interview with S1 conducted on 6/3/2022 indicated that S1 did not accept any gifts from R1 during their time providing care to R1. Interviews with R1 and S1 indicated that a romantic relationship had not been established between the resident and staff member.

Lincoln Police Department report from investigation conducted on 1/6/2022 indicated that R1 stated that they had not been asked for money by S1, but did provide money "to the caretakers" to cover the cost of lost headphones. However, report does not indicate whether S1 or any other caretaker accepted gifts or money from R1. Report does not document any interviews were conducted with S1 or any other staff during investigation conducted on 1/6/2022. Report indicates that R1's relevant party indicated that they were the financial Power of Attorney for R1, but "it was conditional and could be revoked at any time."

Interviews with staff members S2, S3, S4, and Administrator indicated that R1 would flirt with multiple female employees. Interview with Administrator indicated that previous owner of facility also expressed that R1 could be flirtatious with female staff. S2, S3, S4, and Administrator stated that they never witnessed staff members accept gifts or money from residents. S2, S3, S4, and Administrator stated that they never witnessed any inappropriate behavior between a staff member and a resident.

R1's Physician Report (LIC 602) dated 6/7/2018 indicated that R1 was ambulatory, had a primary diagnosis of Parkinson's, and needed a wheelchair or walker. R1's Appraisal/Needs and Services Plan dated 1/20/2019 indicated that R1 needed stand by assistance, "can't walk sometimes," and uses a wheelchair.

R1 was discharged from the facility on 1/17/2022. S1 resigned from being a caregiver at the facility effective 1/9/2022 (per resignation letter).

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20220106130932

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: A LOVING SENIOR CARE HOME II	FACILITY NUMBER: 312700943
	VISIT DATE: 06/28/2022

NARRATIVE

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Based on interviews conducted by the Department and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint 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.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

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