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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700067
Report Date: 11/10/2021
Date Signed: 11/21/2021 10:53:41 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
08/19/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20210819162538
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: 57DATE:
11/10/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Lorraine PadillaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Licensee does not have sufficient staff to meet the needs of the residents
Facility did not report COVID incidents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt and Licensing Program Manager (LPM) Stephenie Doub arrived at the facility unannounced to deliver complaint findings on the above allegations. LPA & LPM met with Administrator Lorraine Padilla and explained the purpose for todays visit.

Regarding the allegation that licensee does not have sufficient staff to meet the needs of the residents. LPA spoke with several residents at the facility. The residents stated on several occasions when they call for assistance, they have had to wait for more than thirty minutes. Residents stated they do get their scheduled showers but often are waiting for long periods of time before staff assists them. Therefore, the allegation is deemed SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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-20210819162538
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: 11/10/2021
NARRATIVE
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Regarding the allegation’s facility did not report COVID incidents. LPA was notified of a COVID positive at the facility through this complaint dated August 19,2021. LPA inquired about the COVID positive staff on August 23, 2021 while conducting the ten day visit to open complaint. LPA collected data to report on the COVID positive and it was discovered the staff member tested positive on August 11, 2021. LPA was not notified by staff of a COVID positive staff. Therefore, this allegation is SUBSTANTIATED.

The following deficiency was cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility staff and a copy of this report along with appeal rights was provided.

Exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20210819162538
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: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [...]
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Administrator will provide staffing plan and submit to licensing by POC date.
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This requirement was not met as evidenced During interviews LPA obtained information that residents are not receiving care and services to meet their needs timely such as scheduled showers due to staffing. This causes potential safety hazard to residents in care.
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Type B
11/17/2021
Section Cited
CCR
87211(a)(2)
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87211(a)(2) Reporting Requirements.
Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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Administrator will conduct training to Administrative staff on reporting requirements and submit proof of training to LPA by POC date.
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This requirement was not evidenced by: Licensee did not report COVID positive within 24 hours.
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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: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 5 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
08/19/2021 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 27-AS-20210819162538

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: 57DATE:
11/10/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Lorraine PadillaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not properly trained to meet needs of residents
Facility did not provide bed linens to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt and Licensing Program Manager (LPM) Stephenie Doub arrived at the facility unannounced to deliver complaint findings on the above allegations. LPA & LPM met with Administrator Lorraine Padilla and explained the purpose for todays visit.

Regarding the allegation that facility did not provide bed linens to resident. LPA observed sheets on all resident beds on two separate visits to the facility. Administrator Lorraine Padilla acknowledges the sheets slide off the hospital beds, but that all residents are provided sheets. Therefore, the allegation is deemed 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 did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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-20210819162538
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: 11/10/2021
NARRATIVE
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Regarding the allegation facility staff are not properly trained to meet needs of residents. LPA reviewed staff training records for several facility staff. The records reviewed showed staff does have required training. Therefore, the allegation is deemed 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 did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5