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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700184
Report Date: 11/26/2024
Date Signed: 11/26/2024 10:36:48 AM

Unfounded


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
10/21/2024 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20241021141241
FACILITY NAME:SHEARWATER RESIDENCEFACILITY NUMBER:
342700184
ADMINISTRATOR:THOMAS, REBECCAFACILITY TYPE:
740
ADDRESS:6526 MAIN AVETELEPHONE:
(916) 989-1060
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:16CENSUS: 13DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Rebecca Thomas TIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Residents care needs are not met.
Staff are not giving residents medications as ordered by doctor.
Staff are rough while providing care to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 11/26/24 to deliver complaint findings for above allegations. LPA met with Administrator, Rebecca Thomas and explained the purpose of the visit.

The department conducted records review ,facility observations and interviews to investigate the complaint.



**Report continued on LIC9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 2
Control Number 59-AS-20241021141241
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: SHEARWATER RESIDENCE
FACILITY NUMBER: 342700184
VISIT DATE: 11/26/2024
NARRATIVE
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**report continued from 9099......
Allegation- Residents care needs are not met.-UNFOUNDED --The department conducted interviews, facility observation and record review to investigate above allegation. During interviews with four (4) facility staff and four (4) residents, it has been discovered that facility was providing appropriate care to the residents based on resident’s documented needs and service plans. During a records review, Department observed facility provided assistance to meet residents care needs. During department visits on 10/22/24 , Department observed that staff were attentive to residents care needs and helping them with their care needs. Four staff interviews reflected that facility provide adequate staffing and there were no issues with staff not helping residents with their care needs. Residents interviews indicated their satisfaction with their care needs and did not express any concerns in this area, therefore this allegation is UNFOUNDED.

Allegation- Staff are not giving residents medications as ordered by doctor. - UNFOUNDED--Based on the information provided, the investigation conducted by the department involved facility observations, record review, and interviews with staff and residents to investigate the complaint allegation. During these interviews with four (4) staff and four (4) residents, it was revealed that the facility dispensed all residents' medications on time and administered them as scheduled. Residents’ interviews indicated that staff were assisting them with their medications without any issues. Furthermore, a review of the records for the month of October 2024, indicated that the facility maintained a proper logs for all medications in the centrally stored medication log, following physician's orders, and documenting them in the Medication Administration Record (MAR) without any errors. Staff interviews reflected that residents were given medications on time per their physician’s orders and there were no problems to address. Based on these findings, this allegation is considered UNFOUNDED.

Allegation- Staff are rough while providing care to residents.-- Unfounded- During investigation, Licensing Program Analyst (LPA) Bains interviewed four (4) residents and four (4) staff to investigate this allegation. Based on interviews that was conducted with four residents, residents stated that they did not witness staff handling residents in rough manner. One of four residents interview reflected that they prefer not to work with one of the staff who work there, and facility was acknowledging their request. Four Staff who were interviewed stated that they have not observe other staff being rough with residents in any manner. Staff interviews indicated that sometimes staff talk loud to each other which could have been perceived as threatening tone or some staff having strong personalities , but staff treat all residents with respect and dignity and work at facility in a professional manner. Furthermore, Department did not observe any kind of bruising, body marks or any other injury related to staff being rough with residents in facility’s records and documentation. Based on gathered information, this allegation was found to be UNFOUNDED.

A finding that the allegations are Unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis. Exit interview conducted. A copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2