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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002096
Report Date: 03/01/2022
Date Signed: 03/01/2022 01:43:11 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
09/30/2021 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210930162233
FACILITY NAME:LOOMIS HOME CAREFACILITY NUMBER:
315002096
ADMINISTRATOR:MILE, PETREFACILITY TYPE:
740
ADDRESS:7964 RASMUSSEN RD.TELEPHONE:
(916) 705-3318
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:6CENSUS: 4DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Petre Mile TIME COMPLETED:
01:50 PM
ALLEGATION(S):
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- Resident not allowed to converse with other residents.
- Facility is witholding personal property.
- Staff did not allow resident to receive occupational therapy services.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 03/01/2022 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 09/30/2021. LPA met with Licensee, Petre Mile, 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 COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment at the facility. LPA ensured the following Personal Protective Equipment (PPE) was worn Surgical Mask.

Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents relevant to the allegation listed above.The Department had requested the facility to submit staff roster, resident roster, resident’s (R1’s) LIC 624 Physician’s report, admission agreement and medical documents.

Allegation: Resident not allowed to converse with other residents. - Unfounded.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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 6
Control Number 25-AS-20210930162233
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: LOOMIS HOME CARE
FACILITY NUMBER: 315002096
VISIT DATE: 03/01/2022
NARRATIVE
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The Department received statement from a total of four (4) residents and two (2) facility staff. Statement received from all four (4) residents were consistent. All residents denied that the facility does not allowed resident to converse with one another.

Allegation: Facility is withholding personal property. – Unfounded.

According to complainant, R1’s T.V was not installed in the bedroom and R1’s magnifying glass to help assist with reading has not been returned to R1. R1's audio book recorder has gone missing. On 10/07/2021, the Department investigated and observed a T.V installed in R1’s bedroom. Interview with R1 revealed that there was no need for Licensee to install R1’s T.V in the bedroom because there was one installed and ready to be used.

Interview with Licensee indicated that R1 had moved into the facility about two (2) months ago. R1 had personal belongings that needed to be stored such as furniture. Licensee stated he usually do not allow residents to store personal belongings at the facility, but he made an exception for R1.

Interview statement received from R1 indicated that T.V, magnifying glasses, and audio book recorder had all been located.

Allegation: Staff did not allow resident to receive occupational therapy services. – Unfounded.



According to Complainant, R1 had an appointment at the facility with Physical Therapist but Licensee refused the appointment for R1.

The Department received a total of three (3) interview statements from Clinical (CS) Supervisors and PT. CS1 stated R1 had completed all occupational therapy sessions. There was a total of four (4) weeks of sessions with R1 at the facility. Interview statement received from CS2 indicated R1’s first physical therapy session was on 09/02/2021 and the last session was on 09/24/2021. Interview statement received from CS2 revealed that Licensee had not refused physical therapy session for R1.

Interview with PT revealed that Licensee had restricted certain areas at the facility for PT to use while working with R1. PT stated Licensee had an issue with PT walking around the facility and requested for PT to work with R1 in the bedroom. PT mentioned R1’s sessions were also conducted outside. PT stated Licensee had never refused entry. PT stated reasons for restriction given by Licensee is due to COVID-19.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20210930162233
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: LOOMIS HOME CARE
FACILITY NUMBER: 315002096
VISIT DATE: 03/01/2022
NARRATIVE
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Interview statement received from Licensee indicated that the PT working with R1 at the facility was using common areas, entering other residents’ bedrooms, and working in other residents’ bedrooms. Licensee had asked PT to work with R1 in R1’s bedroom and to not go into other residents’ bedrooms. Licensee asked PT and R1 to work in R1’s bedroom or outside the facility. Licensee stated he has never denied resident from receiving physical therapy.

This agency has investigated the complaint alleging resident not allowed to converse with other residents and facility is withholding personal property. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

An exit interview conducted and report left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
09/30/2021 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210930162233

FACILITY NAME:LOOMIS HOME CAREFACILITY NUMBER:
315002096
ADMINISTRATOR:MILE, PETREFACILITY TYPE:
740
ADDRESS:7964 RASMUSSEN RD.TELEPHONE:
(916) 705-3318
CITY:LOOMISSTATE: CAZIP CODE:
95650
CAPACITY:6CENSUS: 4DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Petre Mile TIME COMPLETED:
01:50 PM
ALLEGATION(S):
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No activities provided.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 03/01/2022 to deliver a complaint finding for a complaint Community Care Licensing (CCL) received on 09/30/2021. LPA met with Licensee, Petre Mile, 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 COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment at the facility. LPA ensured the following Personal Protective Equipment (PPE) was worn Surgical Mask.

The Department reviewed the facility’s program description. According to the facility’s program description, residents will have activities that are designed for their enjoyment, exercise, and further learning of past and current events. Activities will include social, educational, and recreational activities such as exercise, music, crafts, outings, and education topes. Activities are planned daily and will be led by the facility staff and volunteers from the community. The facility’s policy and protocol for activities states special equipment and supplies necessary to accommodate physically handicapped persons or other person with special needs will be provided as appropriate.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20210930162233
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: LOOMIS HOME CARE
FACILITY NUMBER: 315002096
VISIT DATE: 03/01/2022
NARRATIVE
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It was discovered that some activities are being provided to residents in care, however; facility is not providing activities beneficial to residents with limitations (e.g residents in wheelchairs).

The Department received interview statements from a total of four (4) residents. Interview with R1 indicated activities is provided by the facility such as walking, socializing, crochet, and card games. Interview statement from R2 and R3 indicated the facility does not provide activities. R4 stated is limited to activities but would like to go on walks but does not think staff would allow it. Interview statement received from Licensee indicated residents are not interested in activities. Licensee stated the facility provide books and magazines to residents. Most of the time residents watch TV and socialize with each other. Licensee also mentioned all but one resident is in a wheelchair so physical activities are limited. Licensee stated program description planned activities calendar is outdated and the facility does not follow it.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20210930162233
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: LOOMIS HOME CARE
FACILITY NUMBER: 315002096
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2022
Section Cited
CCR
87219(a)(4)
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87219 Planned Activities. (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:(4) Physical activities such as games, sports and exercise which develop and maintain strength, coordination and range of motion.
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Licensee agrees to create new planned activities calendar to incorporate physical activities to promote strength, coordination, and range of motion. Calendar is to be completed and submitted to CCL by POC due date, 03/08/2022.
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This requirement is not met as evidenced by: Based on interview statements from residents in care and Licensee. No physical activities are provided to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6