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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700067
Report Date: 07/22/2021
Date Signed: 07/22/2021 04:41:51 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
05/10/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210510100938
FACILITY NAME:HOSPITALITY HOUSEFACILITY NUMBER:
342700067
ADMINISTRATOR:SONYA SMITHFACILITY TYPE:
740
ADDRESS:5400 KIERNAN AVENUETELEPHONE:
(209) 543-9275
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 48DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Loraraine Padilla, Executive DirectorTIME COMPLETED:
11:28 AM
ALLEGATION(S):
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Staff are not providing water to residents.
Not enough staff to meet the residents' needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Hospitality House to deliver the finding of the above allegations. LPA met with Loraraine Padilla, Executive Director.

The initial 10 day Visit was conducted on 5/18/2021.

Through the course of the investigation, LPA conducted interviews, reviewed staff/ resident records and facility records. It was alleged that there was not enough staff to meet the residents needs and staff are not providing water to residents.

9099 CONT. >>>>>>>>>>
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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 5
Control Number 27-AS-20210510100938
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: 07/22/2021
NARRATIVE
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9099 CONT: >>>>>>>>>>>>>>

LPA interviewed Executive Director (ED), Office Manager (OM), two staff and two residents. LPAs reviewed staff schedules. LPAs toured facility and observed 2 administrators, 2 kitchen staff, 2 caregivers and 2 med techs in memory care, 2 caregivers and 2 medtechs in Assisted Living. LPA observed sufficient staff to support residents when pendant was pushed. LPA observed sufficient staff when assistance was needed in dining hall. LPAs observed water jugs available for the residents in both Assisted Living and Memory Care Dining halls. LPA observed additional water jugs available in the kitchen area. LPA observed bottled water in 2 rooms in Assisted Living and 2 rooms in Memory Care. Interviews confirmed no concerns from residents in the care they were receiving.

Therefore, the allegation that the there was not enough staff to meet residents needs and staff are not providing water to residents is deemed UNSUBSTANTIATED. There was not a preponderance of evidence to prove or disprove that the allegation occurred as reported therefore the allegation was found to be Unsubstantiated.

An exit interview was conducted with Loraraine Padilla, Executive Director and a copy of this report 9099-A and Appeal Rights was provided to the Administrator via email.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
05/10/2021 and conducted by Evaluator Arlene D Garcia
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210510100938

FACILITY NAME:HOSPITALITY HOUSEFACILITY NUMBER:
342700067
ADMINISTRATOR:SONYA SMITHFACILITY TYPE:
740
ADDRESS:5400 KIERNAN AVENUETELEPHONE:
(209) 543-9275
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: DATE:
07/22/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Loraraine Padilla, Executive DirectorTIME COMPLETED:
11:28 AM
ALLEGATION(S):
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Facility communication equipment pull-cords and walkies are in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Arlene Garcia made an unannounced visit to Hospitality House to deliver the finding of the above allegations. LPAs met with Loraraine Padilla, Executive Director.

The initial 10 day Visit was conducted on 5/18/2021.

Through the course of the investigation, LPAs conducted interviews, reviewed staff/ resident records and facility records. It was alleged the facility communication equipment pull-cords and walkies are in disrepair.

9099 CONT. >>>>>>>>>>>>>>>>
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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 5
Control Number 27-AS-20210510100938
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: 07/22/2021
NARRATIVE
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9099 CONT. >>>>>>>

Records revealed that the Nurse Call System/Pendant call system was not functioning properly. Call button in an unoccupied Resident Room 101 was activated 77 times. Call button in Room 111 was activated by Resident (R4) on six occasions. Staff responded within minutes, reset system but the pendant continued to announce call seven times after reset. Call button in Room 146 was activated by Resident (R3) on eight occasions. Staff responded within minutes, reset system but the pendant continued to announce call nine times after reset. Office Manager, (OM) stated they have always had issues with walkies and have moved to phone system. Executive Director (ED) stated they have added a second separate land line in the facility, additional cordless phones in both the front office and back office in Memory Care. LPA observed both the land lines and the cordless phones to be functioning properly.

Based on information provided through interviews and records reviewed, the allegations that the facility communication equipment pull-cords and walkies are in disrepair was deemed SUBSTANTIATED. This agency has investigated the allegation noted and have found the allegation to be substantiated, meaning that there was a preponderance of evidence to prove the allegation occurred as reported.

The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview conducted with Loraraine Padilla, Executive Director and a copy of this report was provided.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210510100938
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: 07/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2021
Section Cited
CCR
87303i(1)(A)
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Maintenance and Operation
Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:
(A) Operate from each resident's living unit.
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Licensee will service the pendant system and provide proof of service to LPA by POC date 8/2/2021.
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Based on records reviewed, this facility did not maintain compliance as evidenced by the call buttons in resident rooms 101, 111, and 146 not in proper functioning order. This posed a potential threat to the Health, Safety, and Personal Rights of all residents in care.
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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 DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D GarciaTELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5