342700136-7-15-2022-27-AS-KHOS-CGGKRW-20220719080833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700136
Report Date: 07/15/2022
Date Signed: 07/15/2022 04:44:01 PM

Unsubstantiated

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
05/06/2022 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20220506140228

FACILITY NAME:	HARVEY ESTATE		FACILITY NUMBER:	342700136
ADMINISTRATOR:	KHAN, HANIF		FACILITY TYPE:	735
ADDRESS:	9812 HARVEY ROAD		TELEPHONE:	(209) 329-5689
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY:	4	CENSUS: 4	DATE:	07/15/2022
		UNANNOUNCED	TIME BEGAN:	04:07 PM
MET WITH:	Brittney Chaves		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff working at facility while impaired
Residents are locked out of their rooms
Staff pushing residents.
Residents are refused snacks

INVESTIGATION FINDINGS:

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On 7-15-22 at 4:07pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegations listed above. LPA met with facility manager Brittany Chaves and explained the purpose of the visit. Administrator was notified by phone and gave permission for Brittany to sign in his absence. During this investigation, LPA interviewed Staff1 (S1), S2, S3 on 6-16-22, and S4 and S5 on 6-28-22. LPA also attempted interviews with Resident1 (R1), R2, and R3, and interviewed R4 on 6-16-22. LPA also interviewed Administrator on 6-28-22. Additionally, LPA reviewed Individualized Program Plan (IPP) for R1 and R2 as well as facility program design, facility’s menu for May and June of 2022, and weekday daily schedule for residents in care. Additionally, LPA conducted a facility observation on 6-16-22.
Allegation #1: Staff working at facility while impaired. LPA attempted interviews with R1, R2, R3, and interviewed R4, S1, S2, S3, S4, S5, and Administrator. LPA also conducted facility observation of staff interaction with residents in care on 6-16-22 and reviewed facility program design. Interviews conducted revealed no witnesses of staff working while under the influence. Facility observation revealed no illegal substances in use or observed on facility grounds. {Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

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 3

Control Number 27-AS-20220506140228

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: HARVEY ESTATE	FACILITY NUMBER: 342700136
	VISIT DATE: 07/15/2022

NARRATIVE

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Facility observation also revealed staff conducting duties according to program design. Based on interviews, observation, and record review, there is not a preponderance of evidence to conclude that a staff member or members have worked while impaired, therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Residents are locked out of their rooms. LPA conducted facility observation as well as attempted interviews with R1, R2, and R3. LPA interviewed R4, S1, S2, S3, S4, S5, and Administrator. Facility observation revealed locks contained on resident doors with R4 preferring to keep room locked. Observation and interviews with staff revealed staff has keyed access to resident rooms. Interviews with residents and staff also revealed no accounts of residents being locked out of their rooms at any point in time. Observation on 6-16-22 also revealed that residents are able to access and depart their rooms freely when desired. Based on observation, record review, and interviews there is a not a preponderance of evidence to conclude that residents have been locked out of their rooms, therefore this allegation is UNSUBSTANTIATED.

Allegation #3: Staff pushing residents. LPA conducted facility observation on 6-16-22 and attempted interviews with R1, R2, and R3. LPA also interviewed R4. LPA also observed residents in care and reviewed facility’s program design. Additionally, LPA interviewed S1, S2, S3, S4, S5, and Administrator. Based on observation, it was revealed that staff interacted with residents in care according to program design, with no observation of pushing or otherwise rough handling of residents. Interviews conducted revealed no witness or knowledge of residents in care being pushed by staff. Based on interviews, observation, and record review, it is determined that there is not a preponderance of evidence to conclude that residents in care were pushed by staff. Therefore, this allegation is UNSUBSTANTIATED.

Allegation #4: Residents are refused snacks. LPA conducted facility observation on 6-16-22 and attempted interviews with R1, R2, and R3. LPA also interviewed R4. LPA also observed residents in care and reviewed facility’s program design. Additionally, LPA interviewed S1, S2, S3, S4, S5, and Administrator. Based on observation, it was determined that facility has sufficient amount of snacks available to residents in care. Furthermore, LPA observed residents in care offered snacks during facility observation. LPA’s review of facility’s menu indicates snacks are offered throughout various times of the day. A review of facility’s program and design and interviews with staff and residents revealed that snacks are offered regularly and additionally as a tool for behavior modification. {Cont. on 9099C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220506140228

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: HARVEY ESTATE	FACILITY NUMBER: 342700136
	VISIT DATE: 07/15/2022

NARRATIVE

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Interviews also revealed no witness or knowledge of residents being refused snacks. Based on observation, interview, and record review, it is determined that there is not a preponderance of evidence to conclude that residents in care were denied snacks. As a result, this allegation is UNSUBSTANTIATED.

No deficiencies cited today. An exit interview was conducted with Brittany Chaves and a copy of this report was left with Brittany. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC9099 (FAS) - (06/04)

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