315002873-3-29-2023-25-AS-KHOS-CQKNUF-20230404104617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 315002873
Report Date: 03/29/2023
Date Signed: 03/29/2023 01:33:12 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/29/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221129094726

FACILITY NAME:	CIRBY RANCH SRF		FACILITY NUMBER:	315002873
ADMINISTRATOR:	EZEANI, IFEANYI		FACILITY TYPE:	772
ADDRESS:	1085 SANDRINGHAM WAY		TELEPHONE:	(916) 870-9676
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95661
CAPACITY:	6	CENSUS: 5	DATE:	03/29/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Safaratu Okolo- Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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- Staff not monitoring residents.
- Staff failed to assist residents.

INVESTIGATION FINDINGS:

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On 03/29/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 11/29/2022. LPA met with Administrator, Safaratu Okolo, and explained the purpose of the visit. LPA ensured the following Personal Protective Equipment (PPE) was worn surgical mask.

During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, residents’ roster, residents’ physician’s report, staff schedules, compliance letter from Department of Health Care Services (DHCS), Social Rehabilitation Program Approval certificate, community residential treatment system protocol from DHCS.

Continue on page LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

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-20221129094726

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: CIRBY RANCH SRF	FACILITY NUMBER: 315002873
	VISIT DATE: 03/29/2023

NARRATIVE

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Allegation: Staff not monitoring residents. - Unsubstantiated.

According to complainant, staff is not monitoring residents in care. Resident (R1) and R2 are roommates. R1 and R2 is not compatible. R1 has received constant intimidation, threats, and abuse from R2.

The Department received interview statements from a total of four (4) residents and three (3) staff. Interview statement received from three (3) staff were consistent. S1 indicated, R1 and R2 used to share a bedroom, however, R2 had requested to move to another room. R1 is incontinence and staff would often assist in changing R1 in the middle of the night, which resulted in R2 not getting enough sleep. Interview statement received from R2 indicated, R1 is unable to get enough sleep due to R2 repeatedly calling out for staff. On a daily basis R1 would turn on the lights to get dressed and undress at 2AM. R2 indicated staff would often check on R2 throughout the night. R1 stated R1 and R2 does not have any disagreements. Interview statement received from R1, R2, R3, and R4 indicated, R1 and R2 gets along well with one another. According to staff (S2), staff ratio is being met. There are 2-3 staff scheduled for AM shift and 1 staff working the NOC shift. Rounds are conducted every 30 minutes to check on residents. R3 indicated staff conducts rounds and ask if R3 needs assistance with anything.

The Department received a report of long-term residential treatment system protocol report from the Department of Health Care Services for review. According to report, based on a review of the facility records during the on-site annual program certification review, the facility was found to be in compliance with Title 9, Article 3.5, Section(s) 531 through 533 of the California Code of Regulations. Records of direct service staff staffing hours of January 2023 are consistent with census/staffing ratios as required. On 03/13/2023, the facility is certified to continue providing Long-Term Social Rehabilitation Program Services.

Allegation: Staff failed to assist residents. - Unsubstantiated.

According to R1’s physician’s report, R1 is able to care for all personal needs, can administer and store own medications, bathe self, dress self, feed self, and care for own toilet needs.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221129094726

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: CIRBY RANCH SRF	FACILITY NUMBER: 315002873
	VISIT DATE: 03/29/2023

NARRATIVE

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Interview statement received from S1 indicated, all residents are independent except for R1 who needs prompting with ADLs. S1 stated R1 is incontinence and staff has to prompt R1 to use the bathroom every 2 hours. Interview statement reviewed from S2 indicated, R1 needs more assistance compared to other residents in care. S2 indicated R1 is independent but needs prompting to use the bathroom, take showers, and get dressed. All residents are independent and will complete tasks on their own. They are all self-sufficient. Interview statement received from R1, R2, R3, and R4 stated their needs are being met.

Due to the information above, CCL finds the allegations 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

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

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Sarena Keosavang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023

LIC9099 (FAS) - (06/04)

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