340300522-11-19-2020-27-AS-KHOS-BX2RYB-20210107122604

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340300522
Report Date: 11/19/2020
Date Signed: 11/19/2020 05:49:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/13/2020 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 27-AS-20200213092524

FACILITY NAME:	PIONEER HOUSE		FACILITY NUMBER:	340300522
ADMINISTRATOR:	ROBERT GODFREY		FACILITY TYPE:	740
ADDRESS:	415 P STREET		TELEPHONE:	(916) 442-4906
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95814
CAPACITY:	41	CENSUS: 19	DATE:	11/19/2020
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Robert Godfrey, Executive Director		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Wandergard system is not working properly

INVESTIGATION FINDINGS:

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At around 4:30 PM, Licensing Program Analyst (LPA) Michael Hood contacted the facility via telephone to deliver complaint findings for the above allegation. Findings are delivered via telephone due to COVID-19 pre-cautionary measures. LPA explained the purpose of the call to Executive Director, Robert Godfrey.

During the investigation, LPA Melody Claussen toured the facility, interviewed facility staff, and obtained documentation pertinent to the investigation.

Allegation: WanderGuard system is not working properly.

The allegation indicates that the facility retained residents with dementia with knowledge that the WanderGuard system was not functioning.

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

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 27-AS-20200213092524

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PIONEER HOUSE	FACILITY NUMBER: 340300522
	VISIT DATE: 11/19/2020

NARRATIVE

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During the tour of the facility, LPA Claussen observed that the front of the building lets out onto a busy downtown street. Resident AWOLS were reported by the facility from August 2019 to January 2020. Three residents (R1, R2, and R3) were able to abscond from the building undetected.

The Physician’s Reports (LIC 602) for these residents all indicated they were unable to leave the facility unassisted. Fortunately, no injuries resulted from these incidents.

CCLD conducted case management visits regarding these AWOLS on 8/15/2019 and again on 1/30/2020. It was discovered during the second visit on 1/30/2020 that the WanderGuard system had not been functioning for some time. Staff interviews revealed the facility was aware that the system had not been consistently functioning at least since July 2019 but at the time believed there was an issue with the tags.

On 1/30/2020, Human Resources Manager, Stephanie Butler, informed LPA Claussen that the facility had recently put in a request to get the WanderGuard system repaired. LPA Claussen observed a service agreement dated 1/28/2020, indicating the system was inspected and it was determined that the sensors for the front and back doors of the facility were not working. LPA Claussen observed that the administrator’s signature on the agreement was dated 1/31/2020. LPA Claussen received an email from the facility on 3/6/2020 indicating that the repairs had been made and the WanderGuard system was tested and is now operational.

Based on interviews, observation, and record review, the preponderance of evidence standards has been met, and therefore the allegation is found to be SUBSTANDIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D page.

An exit interview was conducted with the Executive Director via telephone and a copy of this report and Appeal Rights will be provided to the facility via email. This facility shall sign and return a copy to CCLD by mail and print a copy to be retained by the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 27-AS-20200213092524

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PIONEER HOUSE	FACILITY NUMBER: 340300522
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/25/2020 Section Cited CCR 87705(j)	1 2 3 4 5 6 7	87705 - Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.	1 2 3 4 5 6 7	The facility has provided CCL with verification that the WanderGuard system is in working order as of 3/6/2020. As an additional measure, facility agrees to modify its current employment prevention plan to include quicker response times for the search and reporting of a resident who has eloped.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews, facility did not ensure that the WanderGuard system was functioning at all times while retaining residents with dementia. This poses a potential safety risk to the residents in care.	8 9 10 11 12 13 14	Administrator will send an updated elopement prevention plan to CCLD by POC due date 11/25/2020.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

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, 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
02/13/2020 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 27-AS-20200213092524

FACILITY NAME:	PIONEER HOUSE		FACILITY NUMBER:	340300522
ADMINISTRATOR:	ROBERT GODFREY		FACILITY TYPE:	740
ADDRESS:	415 P STREET		TELEPHONE:	(916) 442-4906
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95814
CAPACITY:	41	CENSUS: 19	DATE:	11/19/2020
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Robert Godfrey, Executive Director		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Staff not reporting elopements to appropriate agencies

Staff does not have required training

Staff not maintaining accurate records for residents

INVESTIGATION FINDINGS:

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At around 4:30 PM, Licensing Program Analyst (LPA) Michael Hood contacted the facility via telephone to deliver complaint findings for the above allegation. Findings are delivered via telephone due to COVID-19 pre-cautionary measures. LPA explained the purpose of the call to Executive Director (ED), Robert Godfrey.

During the investigation, LPA Melody Claussen toured the facility, interviewed facility staff, and obtained documentation pertinent to the investigation.

Allegation: Staff not reporting elopements to appropriate agencies.

The allegation indicates that the facility staff were not reporting elopements to CCLD.

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

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 27-AS-20200213092524

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PIONEER HOUSE	FACILITY NUMBER: 340300522
	VISIT DATE: 11/19/2020

NARRATIVE

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It was alleged that the facility did not report an elopement of a resident (R4). On 1/30/2020, R4, who does not have dementia nor MCI but per Physician’s Report (LIC 602) is not able to leave the facility unassisted due to needing physical assistance, went with another resident and that resident’s daughter across the street to have lunch. The resident was escorted back to the building by facility staff. The facility provided LPA Claussen with the written SIR and during a phone call on 1/31/2020, the ED informed this LPA of this incident.

Allegation: Staff does not have required training.

Allegation indicates that not all staff working in the med room have required training. LPA Claussen reviewed staff training documents to reveal that required staff trainings had been conducted or were in process. LPA Claussen was informed by the ED that the Assisted Living Manager, Jeanette Barker, LVN who was hired 9/1/2019 was supposed to go through RCFE Administrator training within six months of hire but that she resigned before the six months had elapsed. LPA Claussen observed a training checklist that was in progress which indicated that training was on-going.

Allegation: Staff not maintaining accurate records for residents.

The allegation indicates that the facility has hidden Physician Reports/LIC 602s in other files in order to conceal the acceptance and retention of residents that might need a higher level of care than the facility can provide (esp. dementia).

During LPA Claussen's visit to the facility on 2/21/2020, the LPA was informed by business office staff that the LIC 602s are kept in two different places. LPA Claussen was told that the current LIC 602s were kept in the med room and older LIC 602s were kept in the business office.

LPA Claussen reviewed resident files in both the business office and med room. LPA Claussen observed LIC 602s for two residents (R2 and R3) which indicated dementia diagnosis. R2 was diagnosed with dementia on 1/9/2016 and R3 diagnosed on 12/17/2019. LPA Claussen found these files were available to her upon request.

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 27-AS-20200213092524

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PIONEER HOUSE	FACILITY NUMBER: 340300522
	VISIT DATE: 11/19/2020

NARRATIVE

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LPA finds these allegations 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.

An exit interview was conducted with the Executive Director via telephone and a copy of this report will be provided to the facility via email. This facility shall sign and return a copy to CCLD by mail and print a copy to be retained by the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020

LIC9099 (FAS) - (06/04)

Page: 6 of 6