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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700073
Report Date: 10/25/2024
Date Signed: 10/25/2024 04:13:11 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20221117150319
FACILITY NAME:PEOPLE'S CARE WINFINFACILITY NUMBER:
342700073
ADMINISTRATOR:EKUNDARE, ADEBIMPEFACILITY TYPE:
735
ADDRESS:3418 WINFIN WAYTELEPHONE:
(916) 480-9660
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:4CENSUS: 3DATE:
10/25/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:John O'Brien, District ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Questionable death.

Facility staff left resident in their urine and feces for an extended period of time.

Facility staff are insufficient at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility's district office and met with District Manager, John O'Brien, to deliver findings into the complaint allegations listed above.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Questionable Death

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
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 10
Control Number 25-AS-20221117150319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073
VISIT DATE: 10/25/2024
NARRATIVE
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Resident (R1) passed away on 11/16/2022 with the cause of death being chlorpromazine toxicity. Although the investigation did not find indications of medication errors or overdose that resulted in chlorpromazine toxicity, the investigation did find several ways the facility neglected R1 that contributed to their death. In September of 2022, R1’s physician recommended R1 be seen by a specialist regarding their behavior of putting themselves on the ground. Staff member (S1) stated that they took R1 to see the recommended specialist but did not mention R1’s change in condition or behaviors during the visit. Interview with specialist indicated that, if they had received the information regarding R1 putting themselves on the ground for extended periods of time, they would have recommended R1 go to the emergency room or have additional laboratory tests completed which would have likely shown high levels of chlorpromazine in R1’s system. Following the medical visit in September of 2022, the hospital made multiple attempts to contact the facility regarding follow up medical care for R1. Facility staff did not return contact with the hospital and R1 subsequently was not medically treated prior to their death.

On 11/15/2022, at approximately 2031 hours, fire department firefighters and paramedics responded to the facility for a lift assist. Multiple firefighters stated, if staff had reported R1 was on the ground for two (2) days, it would have turned into a medical call and a Prehospital Care Report would be generated. There were no Prehospital Care Reports related to this call for service. Therefore, staff did not report R1’s signs of weakness, stomach pain, and change in condition to paramedics on scene hours before their death, thus preventing medical evaluation by paramedics. Multiple staff reported no one checked on R1 overnight from approximately 2200 hours on 11/15/2022 to 0700 hours on 11/16/2022. This violated the facility’s procedure to conduct hourly checks overnight and upon arrival for the shift in the morning. Administrator, Stephanie Henry, stated it is possible, if staff had checked on R1 during the night, their death could have been prevented.

Additionally, in the days leading to R1’s death, R1 reported stomach pain and signs of weakness, which R1’s physician and forensic pathologist stated are symptoms of chlorpromazine toxicity. Based on the toxicology results, R1 had “extremely high” levels of chlorpromazine in their system. If staff had reported R1’s symptoms to medical professionals, they could have changed the medication dosage, ordered additional lab tests, or sent R1 to the emergency room to be evaluated and receive medical treatment. Therefore, it has been determined that neglect and/or lack of supervision contributed to the death of R1.
** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 25-AS-20221117150319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073
VISIT DATE: 10/25/2024
NARRATIVE
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Allegation: Facility staff left resident in their urine and feces for an extended period of time.

Interview with Alta California Regional Center (ACRC) Service Coordinator (SC) indicated that they spoke with staff member (S2), who indicated that R1 was having behaviors a couple days prior to their death and the usual protocol was to call non-emergency police line and obtain assistance, but staff were advised by upper management to leave R1 alone on the floor rather than follow R1’s behavior plan. SC stated that S2 indicated that R1 had been sitting in their feces and urine for a few days prior to their death. Interview with S2 indicated that R1 would throw themselves on the ground one (1) to two (2) times a month. S2 stated that, on 11/16/2024, they were notified by staff member (S3) that R1 was on the floor for two days and was lying in their own feces and urine. S2 stated that S3 was instructed to leave R1 on the floor and not contact 9-1-1 by District Manager, Kourtney Hamilton. Interview with S1 indicated that Administrator did not want staff to contact paramedics for assistance with lifting R1 off the floor and wanted staff to leave R1 on the floor. S1 reported R1 remained on the floor from 11/13/2022 to 11/15/2022. S1 stated that R1 urinated and defecate on themselves while on the floor. Interview with S3 indicated that they were told by Administrator not to call nonemergency services to assist with lifting R1 off the floor. S3 stated that R1 urinated on themselves several times while on the floor. S3 estimated that R1 was on the floor for approximately eighteen (18) hours. Interview with staff member (S4) stated that R1 could not get up off the floor and even went to the “bathroom” on themselves. Interview with staff member (S5) indicated that “management” told staff to leave R1 on the ground and not contact 9-1-1 for assistance. Interview with staff member (S6) indicated that they reported R1 was on the floor to District Manager, who told them to “make [R1] stay there” because it was a “behavior.” S6 stated that District Manager told them not to contact 9-1-1 because R1 could get up when they wanted to. S6 reported that R1 had urinated and defecated on themselves when on the floor on 11/15/2022. S6 stated that they did not think staff cleaned R1 for up to two (2) days prior to 11/15/2022 when S6 gave R1 a bed bath and change of clothes. Interview with staff member (S7) indicated that R1 has been left on the floor for nine (9) hours and urinated on themselves while on the floor. Multiple staff reported R1 was left on the ground for an extended period of time, R1 defecated and urinated on themselves, and staff were not allowed to call 911 or a nonemergency line for a lift assist for R1 and needed permission from management to make the call. Staff reported that management denied them permission to call 911 or a nonemergency line for a lift assist for R1.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 10
Control Number 25-AS-20221117150319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073
VISIT DATE: 10/25/2024
NARRATIVE
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The Department received “T-Log” reports from the facility regarding R1. On 9/14/2022, it was documented that staff encouraged R1 to go to the bathroom and take a shower because they had spent most of the day on the floor while soiled. On 9/15/2022, it was documented that overnight shift staff stated that R1 had been on the floor since 4:00 AM. Staff tried to encourage R1 to get up throughout the day but R1 refused to get up from the floor. R1 smacked their head and scratched their hand. R1 urinated on themselves twice during the morning shift. There is no indication that R1 was changed or received a shower regarding entry. T-Log lacks records of R1 being sent out to the hospital. On 9/16/2022, it was documented that staff took R1 to hospital to get a foot X-ray but R1 could not get out of the van. There was no note whether staff were able to get R1 out of the van and there are no records from the hospital that R1 received an X-ray during that timeframe.

The Facility Program Description’s Discipline Policy states, “People’s Care utilizes only positive reinforcements. Under no circumstance will any form of corporal punishment or any violation of personal rights be tolerated. We will make every effort to implement contingencies which positively reinforce target behaviors and decrease or fade inappropriate behaviors.”

Allegation: Facility staff are insufficient at the facility.

Interview with ACRC SC indicated that they spoke with S2, who indicated that they had concerns about the lack of support from management and the facility being constantly understaffed. Interview with S2 indicated that they worked more than one hundred and forty (140) hours over a two (2) week period due to the facility not having enough staff. Interview with S1 indicated that they were working more than sixty (60) hours a week and worked one hundred and fifty one (151) hours over a two (2) week period with no days off. S1 stated there are hardly ever three (3) staff present at the facility. Interview with S3 indicated that the facility didn’t have sufficient staff and five caregivers cover all three shifts. Interview with S5 indicated that they have been the only staff on duty due to facility not having enough staff. S5 stated that they’ve been left alone to care for three (3) clients. Interview with S7 reported that the facility was constantly short staffed. Interview with Administrator indicated that they stepped down as Administrator due to lack of staff and being “on call 24/7.”

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 25-AS-20221117150319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073
VISIT DATE: 10/25/2024
NARRATIVE
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Interview with R1’s day program transportation aide (TA) indicated that they observed R1 was not getting a lot of attention. TA stated that they observed R1 not receive breakfast before day program and did not have a good schedule in place at the care home. TA stated that staff at the care home appeared “overworked” and reported working twenty-seven (27) hours without breaks.

Based on payroll records provided, the facility submitted falsified payroll records to the Department that stated there were no staff working from approximately 2310 hours on 11/15/2022 to 0600 hours on 11/16/2022.

The Department obtained a staff schedule for November 2022, which showed that no staff were scheduled to work from 10:00 PM 11/15/2022 to 6:00 AM 11/16/2022. The Department obtained an Excel spreadsheet for timekeeping payroll records from the facility for November 2022 and observed that no staff were on duty between 11:20 PM 11/15/2022 and 6:00 AM 11/16/2022. A review of the facility staffing schedule indicates that two Direct Support Professional staff are to be on duty between 10:00 PM and 6:00 AM seven days a week. A review of the Facility Program Description indicates “This is a staff operated facility with 24/7 staff support for adults who require intense supervision and training for behavioral issues, as well as deficits in self-help skills and adaptive functioning.” The facility is required to have “24 hour awake supervision.”

Interview with S1 indicated that staff member (S4) worked from 2200 hours on 11/15/2022 to 1400 hours on 11/16/2022. Interview with S4 indicated that they had reported to work at 2200 hours on 11/15/2022 and checked on R1 at 0200 hours and 0300 hours on 11/16/2022 by looking at R1 from the doorway without entering the room. S4 stated that they had not checked on R1 the rest of the night. Interview with staff member (S8) indicated that it was too dark in R1’s room to see R1 from the doorway.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 25-AS-20221117150319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073
VISIT DATE: 10/25/2024
NARRATIVE
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Interview with staff member (S9) indicated that they worked with S4 on 11/15/2022 at 2200 hours. S9 could only identify 0520 hours on 11/16/2022 as a specific time they checked on R1 and stated that they checked on R1 from the doorway. Interview with Administrator indicated that overnight staff were to check on resident every hour by walking into the room and visually seeing the resident’s chest going up and down. Administrator stated that looking at the resident from the doorway would not be sufficient. Administrator stated that they heard that S4 and S9 had not checked on R1 during the 11/15/2022-11/16/2022 overnight shift. Interview with District Manager indicated that they spoke with S4 and S9, who told them that they didn’t need to check on R1 due to R1 being “independent.” District Manager indicated that S4 and S9 had violated the facility’s protocol for overnight staff.

Based on interviews conducted and records reviewed by the Department, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. As a result of the resident’s serious bodily injury, an immediate civil penalty per Health and Safety Code § 1548 in the amount of $500 for the date of 10/24/2024 is assessed for a violation that the Department determines resulted in the injury or illness of a person in care. An additional civil penalty assessment is under review and a determination is pending. LPA will return on a future date to assess an additional civil penalty if warranted.

Exit interview was conducted with District Manager. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 25-AS-20221117150319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
85075.4(c)
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85075.4 Observation of the Client (c) The licensee shall bring observed changes, including but not limited to (...) deterioration of health condition, to the attention of the client's physician and authorized representative, if any. This requirement is not met as evidenced by:
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Facility will conduct an in-service training for all staff regarding observation of residents in care. Facility will submit date and materials of training to LPA by POC due date. An immediate civil penalty of $500 was assessed due to a violation that resulted in the serious bodily injury of a resident in care.
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Based on interviews conducted and records reviewed, the facility did not bring changes in resident R1's behavior to the attention of R1's physician or paramedics, resulting in R1's death, which poses an immediate health, safety, and personal reights risk to the residents in care.
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Type A
10/26/2024
Section Cited
CCR
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80072 Personal Rights (a) (...) each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by:
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Facility will conduct an in-service training for all staff regarding personal rights of residents. Facility will submit date and materials of training to LPA by POC due date.
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Based on interviews conducted and records reviewed, the facility did not ensure R1's personal rights were protected when left on the floor in the urine and feces and denied assistance over the course of approximately two (2) days, which poses an immediate health, safety, and personal reights risk to the 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 25-AS-20221117150319
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PEOPLE'S CARE WINFIN
FACILITY NUMBER: 342700073
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2024
Section Cited
CCR
80065(a)
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80065 Personnel Requirements (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement is not met as evidenced by:
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Facility will conduct an in-service training for all staff regarding personnel requirements. Facility will submit date and materials of training to LPA by POC due date.
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Based on interviews conducted and records reviewed, the facility did not ensure staff were competent to provide services necessary to meet residents' needs, resulting in R1 not receiving timely assitance with behaviors or overnight checks from care staff, which poses an immediate health, safety, and personal reights risk to the 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 10