342700067-5-24-2022-27-AS-KHOS-CFEKGZ-20220615075422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700067
Report Date: 05/20/2022
Date Signed: 05/24/2022 02:13:28 PM

Substantiated

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
05/16/2022 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220516084625

FACILITY NAME:	HOSPITALITY HOUSE		FACILITY NUMBER:	342700067
ADMINISTRATOR:	LORRAINE PADILLA		FACILITY TYPE:	740
ADDRESS:	5400 KIERNAN AVENUE		TELEPHONE:	(209) 543-9275
CITY:	SALIDA	STATE: CA	ZIP CODE:	95368
CAPACITY:	80	CENSUS: 37	DATE:	05/20/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Sabrina Duarte		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility does not maintain an operable telephone system

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 05/20/2022 by Licensing Program Analysts (LPAs) Charlie Yang and Arielle Pascua who were met by the Resident Care Director (RCD), Sabrina Duarte.
Current census was 37 residents.
The purpose of this visit was to investigate the allegation above and gather any, and all, information in relation to this investigation.
LPAs conducted a brief interview with RCD, Sabrina Duarte. RCD Duarte stated that the phones in the memory care unit have been down for at least a week. It was learned that a former resident, R1, was aggressive and physically damaged the phone in that area.
As a result, there was not a functional phone in place in the memory care unit for outside family members to reach their loved ones after this incident took place.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

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-20220516084625

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: 05/20/2022

NARRATIVE

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As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed, reviewed, and a copy was left with the facility designated Administrator at this time.

Exit Interview.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220516084625

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/27/2022 Section Cited CCR 87468.1(a)(14)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive	1 2 3 4 5 6 7	Facility representative stated that a phone will be made available until a replacement phone will be purchased and put into place. Facility will provide a statement of correction, along with copy of new phone purchase receipt, and will be submitted into CCL for review by this LPA by 5/27/2022.
	8 9 10 11 12 13 14	confidential calls. The licensee may require reimbursement for long distance calls. This facility was found deficient as evidenced by observation that the phone in the memory care unit was inoperable for use by the residents. This posed a potential threat to the health, safety, and personal rights of the residents in care.	8 9 10 11 12 13 14
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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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022

LIC9099 (FAS) - (06/04)

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