342700067-4-1-2021-27-AS-KHOS-BZNN4E-20210401100748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700067
Report Date: 03/30/2021
Date Signed: 04/01/2021 09:49:23 AM

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
10/09/2020 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201009155835

FACILITY NAME:	HOSPITALITY HOUSE		FACILITY NUMBER:	342700067
ADMINISTRATOR:	SONYA SMITH		FACILITY TYPE:	740
ADDRESS:	5400 KIERNAN AVENUE		TELEPHONE:	(209) 543-9275
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	80	CENSUS: 49	DATE:	03/30/2021
		UNANNOUNCED	TIME BEGAN:	10:33 AM
MET WITH:	Sonya Smith		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff not scheduled to meet residents needs.

INVESTIGATION FINDINGS:

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Allegation:Staff not scheduled to meet residents needs

Based on records review and interviews with the Administrator, the following was discovered:
On October 1, 2020 the reported date of the incident, staff schedule included 2 caregivers in memory care and 1 in assisted living and 1 med tech for the AM shift and 2 caregivers in memory care and 1 in assisted living and 1 med tech fo the PM shift and one med tech and one caregiver for overnight shift.

The information provide does not confirm or deny that residents needs were not met on this day. The facility uses this staffing ratio to meet the needs of the residents for each shift. The department has not recieved reports of residents needs not being met.
Continued

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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 27-AS-20201009155835

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: HOSPITALITY HOUSE	FACILITY NUMBER: 342700067
	VISIT DATE: 03/30/2021

NARRATIVE

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the complaint addresses a need for the staff to have the required breaks and lunch as part of labor law requirements. The reported information will be cross reported to the labor board, however it does not confirm that the residents in care needs are not being met.

As a result of this investigation, and based on LPA’s observations, and interviews the allegation(s) is deemed to be UNSUBSTANTIATED - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited.

An exit interview was conducted with Administrator via telephone and a copy of 9099 and 811(Confidential Names) was provided to the Administrator via email, an electronic email read receipt confirms receiving these documents. Administrator will sign 9099, and send back electronic email to LPA Johnson on today's date.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC9099 (FAS) - (06/04)

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