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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700184
Report Date: 12/10/2024
Date Signed: 12/10/2024 12:25:44 PM

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
11/22/2024 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20241122161951
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:
12/10/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Rebecca Thomas TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility staff did not follow admission agreement.
Facility staff did not meet resident's incontinence care needs.
Facility staff did not maintain resident's bedroom floors clean.
Facility staff did not meet resident's dental care needs.
Facility staff did not communicate with hospice as needed.
Facility staff spoke inappropriately to resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 12/10/24 to deliver complaint findings for above allegations. LPA was greeted by staff and staff called Administrator, Rebecca Thomas who came to the facility after short while. LPA expained the purpose of today's visit.

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



**Report continued on LIC9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 3
Control Number 59-AS-20241122161951
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: 12/10/2024
NARRATIVE
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***Report Continued from 9099.....

Allegation- Facility staff did not follow admission agreement. Facility staff did not communicate with hospice as needed. -Unfounded

During investigation, the Department interviewed four (4) residents and four (4) staff and reviewed records to investigate this allegation. Record review indicated that facility kept proper documentation regarding residents’ admission agreements, hospice care plan for hospice care residents and other required components regarding resident’s care per Department’s Regulations. Resident’s interviews reflected that facility was meeting their care needs per their needs and service plan and per admission agreements and there were no problems. Staff interviews indicated that they were aware about residents’ care needs per their needs and service plans and hospice care plan for hospice care residents and providing care accordingly without any issues. Interview with hospice agency regarding resident, R1s care did not reflected any care concerns while R1 resided at the facility from November 2023 till October 2024. Based on gathered information, this allegation was found to be UNFOUNDED.

Allegation- Facility staff did not meet resident's incontinence care needs. Facility staff did not meet resident's dental care needs.- 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 department visits on 11/26/24, 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. Staff stated that they were assisting residents with toileting needs every 2 hours or as needed without any issues. Resident’s interviews indicated their satisfaction with their care needs including toileting, dental, showers and other care needs and did not express any concerns in this area, therefore this allegation is UNFOUNDED.

(report continued....)

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20241122161951
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: 12/10/2024
NARRATIVE
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***Report continued from 9099....

Allegation- Facility staff did not maintain resident's bedroom floors clean. -Unfounded

On 11/26/24, Department conducted a tour at the facility and observed the facility to be clean, safe, sanitary, and in good repair. An inspection of the facility was conducted and there was no dirt or smell observed. LPA found the kitchen appliances, floors, and food preparation areas to be clean and free from dirt and other debris. Four (4) staff interviews indicated that facility was in good repair and did not report any problems with any housekeeping issues. Staff interviews stated that staff kept facility clean and sanitary. Four (4) residents interviews indicated that there were no issues with facility's housekeeping and maintenance services, therefore this allegation is Unfounded.

Allegation- Facility staff spoke inappropriately to resident. -Unfounded

During investigation, the Department 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 or staff speaking in inappropriate manner with residents. Four Staff who were interviewed stated that they have not observe other staff being rough or having inappropriate interaction from staff to 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. 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.


SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3