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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700184
Report Date: 03/10/2022
Date Signed: 03/10/2022 10:28:51 AM

Substantiated


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
10/12/2021 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20211012115412
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: 14DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Teresa DingerTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Staff speak inappropriately to resident(s) in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Kevin Mknelly, arrived at the facility unannounced on 03/10/2022 to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility.

LPA investigation the allegation " Staff speak inappropriately to resident(s) in care.” A former caregiver admitted to LPA Mknelly during an interview that the former caregiver was terminated due to raising voice at residents. The caregiver was terminated by the facility when it was discovered. LPA Hiratsuka, also interviewed a former resident’s family member who also stated the former caregiver talked inappropriately at the former resident on several occasions. LPA was unable to interview the former resident. Other residents interviewed stated they have not had anyone speak to them inappropriately.
Based on the above, the allegation is substantiated. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.
House Manager was informed to refuse to sign report by Licensee. LPAs unable to wait for Licensee to arrive to go over report due to time constraints.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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 7
Control Number 25-AS-20211012115412
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: 03/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/08/2022
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.
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By 04/08/2022, the Licensee shall submit in writing staff will have personal rights training and how they shall ensure staff treat residents with dignity.
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This requirement was not met as evidenced by a former caregiver admitting they raised their voice to residents this poses an immediate hazard to residents.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
10/12/2021 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20211012115412

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: 14DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Teresa DingerTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Unsubstantiated
1. Staff neglected resident(s).
2. Staff handle resident(s) in a rough manner resulting in injuries.
3. Staff did not provide adequate supervision of resident resulting in a fall.
4. Resident(s) toileting needs not being met.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Kevin Mknelly, arrived at the facility unannounced on 03/10/2022 to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility.
1. LPA Hiratsuka, interviewed residents and staff on 10/13/2021, and 10/27/2021. LPA also interviewed former caregiver, Complainant, and a couple of witnesses. LPA reviewed facility records for residents. Residents and one witness interviewed stated they have no issues with staff. Staff and one witness all stated they did not observe any neglect. Complainant and a second witness stated they witnessed residents waiting for over 20 minutes up to almost an hour before a caregiver responded to a resident pushing the call button for help. LPA was told this occurred between September 2021 to the middle of October 2021. Title 22 regulations do not require facilities to keep response times for call buttons so LPA cannot prove or disprove the call response times occurred. Because there are several versions of events during the time frame the allegation cannot be proved or disproved. Allegation unsubstantiated.
House Manager was informed to refuse to sign report by Licensee.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
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 7
Control Number 25-AS-20211012115412
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: 03/10/2022
NARRATIVE
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2. LPA Hiratsuka, interviewed residents and staff on 10/13/2021, and 10/27/2021. LPA also interviewed former caregiver, Complainant, and a couple of witnesses. LPA reviewed facility records for residents. Residents and one witness interviewed stated they have no issues with staff. LPA was informed staff are repeated told to watch what they are doing when transporting residents because the hallways have just enough space to maneuver someone who is in a wheelchair in and out of the hallways. Caregivers and one resident stated that caregivers have bumped the resident into the wall while trying to get the resident in the hallway to their room, but there were no injuries, the caregiver that was moving the resident very slowly, was being very careful and talking the resident through the maneuver, it was not intentional, and it doesn’t happen often. Complainant stated residents had bruises on their arms and legs caused by the rough manner. A witness stated they saw caregivers banging a former resident into stuff. LPA was unable to interview the former resident. A former caregiver denied banging residents into stuff. LPA did not observe any bruises. Because there are several versions of events, LPA cannot prove or disprove the allegation. Allegation unsubstantiated.
3. LPA Hiratsuka, reviewed the resident in question’s file, interviewed the one of the caregivers on duty and a former caregiver who was on duty, and unable to interview the resident who moved out due to their injuries. The facility incident report stated the resident was observed earlier in the day attempting to get up without assistance and one caregiver was walking by and was able to assist the resident from getting up and then a short time later the caregivers on duty heard a sound come from the resident’s room and found the resident on the floor. The facility records and interviews all state the resident did not have a history of getting out of bed without assistance and would wait for someone to show up to assist after pressing the call button. The caregiver who stopped to assist the resident stated that was the first time the resident was observed attempting to get up without calling for help. The former caregiver stated they had just left the resident’s room after visiting with the resident and was walking to another resident’s room when they heard a sound and found the resident in question on the floor with severe injuries. Caregivers called 911 and the resident was taken to the hospital and did not return due to requiring higher level of care. All caregivers interviewed stated all residents are fall risks and they do frequent checks on residents. They stated there is one caregiver constantly walking around checking on residents. Title 22 regulations does not require residents to be with caregivers all the time. The regulations require a written plan of care that tells caregivers what residents require assistance with and approximately how often a resident should be checked on. The regulations require the facility to update the plans of care when there is a change in condition or every 12 months; whichever comes first. There are times where a resident requires one-on-one supervision and when that happens the facility may provide the caregiver, or the family may provide the caregiver and there’s a written agreement addressing the issue. LPA cannot prove or disprove the resident fell because of lack of supervision. Allegation unsubstantiated. House Manager was informed to refuse to sign report by Licensee.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 25-AS-20211012115412
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: 03/10/2022
NARRATIVE
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4. LPA Hiratsuka, interviewed the one of the caregivers on duty and a former caregiver who was on duty and residents. LPA was informed a former caregiver was not changing residents during the NOC shift and left residents soiled in the morning. LPA contacted the former caregiver and the former caregiver denied not changing residents. The former caregiver stated they changed the residents who required it during the late night/early morning hours and made sure everyone was changed at least once before the shift ended. The former caregiver stated they did not leave anyone soiled. Complainant and witness stated there was at least one instance of the former caregiver leaving residents soiled. LPA interviewed the residents and found no complaints. LPA cannot prove or disprove the allegation. Allegation unsubstantiated.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
10/12/2021 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20211012115412

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: 14DATE:
03/10/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Teresa DingerTIME COMPLETED:
10:40 AM
ALLEGATION(S):
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Resident(s) are not being provided clean bedding.
Resident(s) room is malodorous.
Resident(s) room is unsanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Kevin Mknelly, arrived at the facility unannounced on 03/10/2022 to conduct a Complaint Investigation Visit. LPA conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility.

LPA Hiratsuka, interviewed residents and staff on 10/13/2021, and 10/27/2021. LPA also interviewed a witness, Complainant, and former caregiver. LPA toured the facility on both days. LPA Mknelly also toured the facility and did not find any dirty bedding, smells, or dirty rooms. LPA did not find any dirty bedding, smells, or dirty rooms. LPA was told there was a plumbing issue one day, but it was confined to one bathroom and was addressed immediately. LPA was told due to the plumber not being able to come out the same day the bathroom did smell, but the bathroom was made inaccessible to residents and the window in the bathroom as well windows around the bathroom were left open to circulate the air and the area was cleaned while waiting and deep cleaned after it was repaired. Residents stated the caregivers clean all the time and take out trash all the time. The witness stated the place is very clean. Based on all the above, the allegation is unfounded. House Manager was informed to refuse to sign report by Licensee.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 25-AS-20211012115412
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: 03/10/2022
NARRATIVE
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“This agency has investigated the complaint alleging; Resident(s) are not being provided clean bedding; Resident(s) room is malodorous; and Resident(s) room is unsanitary.. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."

House Manager was informed to refuse to sign report by Licensee.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7