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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 315002965
Report Date: 11/21/2024
Date Signed: 11/21/2024 02:15:16 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20241004140804
FACILITY NAME:JOY'S CARE HOME - HICKORYFACILITY NUMBER:
315002965
ADMINISTRATOR:SUSBILLA, GLORIA JOYCE BROFACILITY TYPE:
740
ADDRESS:1411 HICKORY STREETTELEPHONE:
(916) 297-2675
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 2DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Joy Bron-SusbillaTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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licensee did not follow admission agreement for a rate increase.
INVESTIGATION FINDINGS:
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 On 11/21/24, Licensing Program Analyst (LPA) Kevin Mknelly spoke to designee Joy,to deliver complaint findings for the above allegation.
LPA reviewed resident records, facility records and conducted interviews.
LPA finds that the allegations cited above are substantiated.
Licensee did not follow admission agreement for a rate increase- R1 had a history of swallowing sensitivity that the licensee then charged an additional fee to provide a special prescribed diet of pureed food. Food service and basic services state that modified diets prescribed by a doctor as a medical necessity are a basic service and a optional service fee is not allowable.
As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.
Report reviewed with designee . Copy of this report and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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 59-AS-20241004140804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: JOY'S CARE HOME - HICKORY
FACILITY NUMBER: 315002965
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/12/2024
Section Cited
CCR
87464(f)(3)
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Basic Services(f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity, as specified in Section 87555, General Food Service
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Licensee will review invoices for fees charged to R1 for pureed food service and reimburse resident for pureed food service fees. Licensee will inform LPA of the reimbursement provided by the POC date of 12/12/24.
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Requirements. This requirement was not met based on records review and interviews which found an additional fee was charged for a basic service. This posed a potential risk to the resident.
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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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2024 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 59-AS-20241004140804

FACILITY NAME:JOY'S CARE HOME - HICKORYFACILITY NUMBER:
315002965
ADMINISTRATOR:SUSBILLA, GLORIA JOYCE BROFACILITY TYPE:
740
ADDRESS:1411 HICKORY STREETTELEPHONE:
(916) 297-2675
CITY:ROSEVILLESTATE: CAZIP CODE:
95678
CAPACITY:6CENSUS: 2DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Joy Bron-SusbillaTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility staff did not provide resident privacy in the bathroom.
Facility staff did not interact with resident with dignity and respect.
INVESTIGATION FINDINGS:
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On 11/21/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with xxx xxx.

LPA conducted records review and extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

Facility staff did not provide resident privacy in the bathroom. LPA inspection and interviews found that R1, who uses a wheelchair, due to the size of the bathrooms, needed to request assistance in maneuvering to the toilet and close the bathroom door. Statements found that R1 did not always request the assistance and at other times stated a preference to keep the door open. In interview with R1, R1 stated that they wanted the complaint to be forgotten. R1 had recently moved to this location and was just unhappy with the location. R1 relocated to a new residence that better suits R1 needs for bathroom space.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20241004140804
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: JOY'S CARE HOME - HICKORY
FACILITY NUMBER: 315002965
VISIT DATE: 11/21/2024
NARRATIVE
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Facility staff did not interact with resident with dignity and respect- Interviews conducted found staff were at times frustrated when working with R1. A statement by S1 made to R1’s responsible party regarding the challenges of working with R1. However, S1 denied making derogatory statements to R1. Therefore, as these allegations were not corroborated and witnessed by others, this allegation is unsubstantiated.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint 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 with designee.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4