342700184-1-11-2022-25-AS-KHOS-CB2UXK-20220126145824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700184
Report Date: 01/11/2022
Date Signed: 01/11/2022 11:24:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2021 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20211018161316

FACILITY NAME:	SHEARWATER RESIDENCE		FACILITY NUMBER:	342700184
ADMINISTRATOR:	THOMAS, REBECCA		FACILITY TYPE:	740
ADDRESS:	6526 MAIN AVE		TELEPHONE:	(916) 989-1060
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	16	CENSUS:	DATE:	01/11/2022
		UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Baylee Rippee		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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Facility staff failed to maintain a safe and healthful facility.
Resident fees were wrongly increased.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Mknelly, arrived at the facility unannounced on 1/11/22 to deliver complaint findings. LPA met with . Prior to initiating the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA completed a facility risk assessment upon arrival. Facility is currently under Covid isolation. LPA econducted the visit outside. The following Personal Protective Equipment (PPE) was worn:N-95. Additionally, LPA was screened by .

In the course of the investigation, LPA Mknelly reviewed records and conducted extensive interviews.
LPA finds that the allegations cited above are substantiated.

On 10/21/21, LPA Mknelly interviewed licensee Rebecca “Becky” Thomas. Becky stated that she was aware from video that her staff at times had not adhered to existing public health and Community Care Licensing requirements for staff to wear surgical masks for Covid-19 mitigation in the workplace. Becky later clarified that it

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211018161316

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SHEARWATER RESIDENCE	FACILITY NUMBER: 342700184
	VISIT DATE: 01/11/2022

NARRATIVE

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*** Amended language on this page as of 4/5/22 ***

was not a frequent occurrence and had happened in March 2020. Becky would provide training and supervisor direction whenever infractions were observed. LPA also interviewed people who had visited the facility preceding and during the Covid -19 outbreak of 8/29/21- 10/14/21. Two parties interviewed reported to have observed two staff on two separate occasions to not have worn required masks while at work in the community. Staff interviewed stated that they were aware of others, at times, not wearing required masks prior to the facility’s outbreak, 8/30/21 to 10/15/21.

During the facility’s Covid-19 outbreak residents and staff were infected. The resident infections required residents to be quarantined. The facility enacted a period where all resident were isolated to their rooms. The staff infections lead to a staffing shortage while the staff home quarantined. The licensee utilized home care agency staff to provide care and supervision to the Covid-19 Positive residents who were cohorted. The licensee charged four Covid Positive residents for a share of the cost of the agency staffing.

The residents did not have reappraisals to establish a higher level of care. The facility does not have a fee schedule for various levels of care. The additional charge was based on an operational cost for a staffing shortage which does not qualify as a level of care increase. Operational cost increases require 60-day notices to all residents. One resident who contracted Covid-19 after staff returned from quarantine and thus did not require the facility to hire agency staff, did not have an additional fees charge.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed and copy provided.
Appeal rights provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20211018161316

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: SHEARWATER RESIDENCE	FACILITY NUMBER: 342700184
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 01/19/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:… (2) To be accorded safe, healthful and comfortable accommodations… This requirement was not met as evidenced by statements that found staff at the facility were not consistently following public health guidance for mask wearing.	1 2 3 4 5 6 7	The facility has since enfrced stricy adherence to masking requirements. Licensee will submit a plan for monitoring and enforcement of masking compliance on all shifts. The plan will be submitted by the POC date of 1/19/22.
	8 9 10 11 12 13 14	This posed an immediate risk to residents in care.	8 9 10 11 12 13 14
Request Denied Type B 01/19/2022 Section Cited HSC 1569.655(b)	1 2 3 4 5 6 7	Increase in fee rates for elderly residents. (b) No licensee shall charge nonrecurring lump-sum assessments. .. "nonrecurring lump-sum assessments" mean rate increases due to unavoidable and unexpected costs that financially obligate the licensee...This requirement was not met based on recrds and statements	1 2 3 4 5 6 7	Licensee will submit a statement of understanding of requireents for rate increases to residents as well as a plan to reimburse fees charged to those residents charged for Covid-19 contracted staffing. Plans to be submitted to CCL by the POC date of 1/19/22
	8 9 10 11 12 13 14	that some residents were charged fees for Covid-19 staffing that were a an unexpected and unavoidable cost to the licensee. Residents were not reassessed for level of care and residents did not receive 60 days notice. This violated residents personal rights.	8 9 10 11 12 13 14

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

LIC9099 (FAS) - (06/04)

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