<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700191
Report Date: 02/23/2022
Date Signed: 02/23/2022 04:32:54 PM

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
02/03/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20220203164050
FACILITY NAME:REM CALIFORNIA, LLC - ILLINOISFACILITY NUMBER:
342700191
ADMINISTRATOR:JOYNER, LASHANEFACILITY TYPE:
737
ADDRESS:5035 ILLINOIS AVENUETELEPHONE:
(916) 534-7756
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:4CENSUS: 4DATE:
02/23/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Susana MaganaTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not following Covid-19 protocols
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 2/23/22 to deliver the investigation findings for the allegations above. Prior to 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 ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: n-95 Mask. LPA was not by facility staff but volunteered their screening status.
The department reviewed records and conducted interviews. Statements and records revealed that R1 was Covid-19 Booster eligible when their conservator requested the booster be administered in September 2021.
Arrangements were not made at that time. After R1 cleared isolation in February 2022, they were provided assistance with being vaccinated with the booster at that time.
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. This report was reviewed, copy provided and appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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 2
Control Number 25-AS-20220203164050
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: REM CALIFORNIA, LLC - ILLINOIS
FACILITY NUMBER: 342700191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2022
Section Cited
CCR
80075(a)
1
2
3
4
5
6
7
80075 Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met based on
1
2
3
4
5
6
7
Licensee will submit a statement of understanding of this requirement as well as steps in place to reduce the likelihood of a similar failure to arrange for requested medical care.

Statement to be submitted to CCL by the POC date of 2/24/22.
8
9
10
11
12
13
14
records and statements found R1 was not provided arrangement and transportation to Covid 19 Booster when requested by conservator and eligible.
This posed an immediate risk to resident's health and safety.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2