342700184-10-2-2024-59-AS-APEZ-D9WPCK-20241010111203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700184
Report Date: 10/02/2024
Date Signed: 10/02/2024 11:22:35 AM

Unsubstantiated

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
08/28/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240828114235

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: 13	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator- Rebecca Thomas		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff are not meeting residents needs.
Staff left residents in soiled diapers for extended periods of time.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 10/02/24 to deliver complaint findings for above allegations. LPA met with Administrator, Rebecca Thomas and explained the purpose of the visit.
The Department conducted interviews with staff and residents and reviewed records to investigate the allegation. Department conducted interviews with Administrator, Five (5) staff, and four (4) residents to investigate this allegation. During the interview process it was reported that staff supervise residents twenty-four (24) hours a day and check on residents every two hours to provide residents toilet care needs. It was reported that staff are conscience of keeping the residents clean and dry. Resident’s interviews reflected that staff were providing care per their needs and service plan and there were no issues. LPA toured the facility and facility observed to be clean sanitary and free from odors. LPA did not observe any dirty diapers or smell of urine/feces. Record review reflected that facility has adequate staffing to meet all resident’s needs. It was also noted that facility staff were providing care to residents per their needs and service plan without any issues and keeping documentations records as needed. Based on this information, this allegation is Unsubstantiated.A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Exit interview conducted. Copy of the report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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 4

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
08/28/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240828114235

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: 13	DATE:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator- Rebecca Thomas		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Unqualified staff administering medications.
Staff are not providing activities for residents.
Staff engaged in a verbal altercation with another staff in the presence of residents .
Staff did not ensure the a/c was not in disrepair.
Staff did not ensure residents rooms were not leaking.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 59-AS-20240828114235

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: 10/02/2024

NARRATIVE

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**Report continued from 9099-A.....

Allegation- Unqualified staff administering medications.-UNFOUNDED

The Department conducted interviews with five (5) staff members and reviewed record regarding the allegations cited above. Staff interviews revealed that facility has trained staff who were managing residents’ medications and has access to medication room. Staff interviews denied that any unauthorized person was dispensing residents’ medications. There were some staff who were cross trained to do other duties and those staff also fill-in to do Med Tech job as needed per facility’s staffing needs. Record review indicated that facility has proper documentation of resident’s medication administration and there were no discrepancies. Record review also indicated that facility has proper training records for all staff who were administering resident’s medications per Department’s Regulations. Based on information gathered, this allegation was found to be Unfounded.

Allegation- Staff are not providing activities for residents.-UNFOUNDED

The Department conducted interviews with staff and residents and reviewed records to investigate the allegation. Five (5) staff interviews indicated stated that they offered multiple activities to all residents but most of the residents like to play bingo most of the times. Four Residents interviews indicated that facility was offering a variety of activities and there were no issues to address. Four (4) residents interviews indicated that the facility was providing a variety of activities for the residents to take part in. During department visit, it was observed the facility was providing different activities to residents who wish to participate. Additionally, Department observed monthly activity calendar posted in common areas at the facility, therefore the above allegation is UNFOUNDED.

Allegation- Staff engaged in a verbal altercation with another staff in the presence of residents.-UNFOUNDED

During investigation, Licensing Program Analyst (LPA) Bains interviewed residents and staff to investigate this allegation. Based on interviews that was conducted with four residents, residents stated that they did not witness facility owner, administrator or staff was threatening or had verbal altercation with any staff member. Five Staff who were interviewed stated that they have not observe facility owner threatening any staff member in any manner. Staff interviews indicated that sometimes staff talk loud to each other which could have been perceived as threatening tone, but staff treat everyone with respect and dignity and work at facility in a professional manner, therefore the allegation is UNFOUNDED.

***Report continued...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 59-AS-20240828114235

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: 10/02/2024

NARRATIVE

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**Report continued from 9099-A.....

Allegation- Staff did not ensure the a/c was not in disrepair. Staff did not ensure residents rooms were not leaking.- UNFOUNDED

The Department conducted interviews with staff and residents to investigate the allegation. Four resident’s interviews did not indicate any issues with facility’s physical operations including working A/C unit or any leakage in any residents’ rooms. Residents stated that sometime in August 2024, one of A/C unit was not working properly but facility followed up on that issue in timely manner and that issue has been resolved completely. Residents care or safety were not affected by issues with A/C unit not been working at that time. Five staff interviews reflected that facility A/C was operating without any problems and they were not aware about any water leakage in any rooms. Furthermore, staff stated that facility administration follow up in in timely manner if there were any issues with any physical operations at the facility, therefore the allegation is 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 Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4