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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700237
Report Date: 09/21/2023
Date Signed: 09/21/2023 11:25:03 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
03/21/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230321112340
FACILITY NAME:NELLIE'S ANGELS HOME CAREFACILITY NUMBER:
342700237
ADMINISTRATOR:NELLIE JOHNSONFACILITY TYPE:
740
ADDRESS:6730 SKYLANE DRIVETELEPHONE:
(916) 729-7648
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:9CENSUS: 9DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator: Nellie Johnson TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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- Staff not administering resident's medication as prescribed.
- Facility does not have enough staff to meet the needs of residents in care.
- Staff did not provide adequate food service to resident in care.
- Facility staff was not adequately trained.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 09/21/2023 to deliver complaint finding Community Care Licensing (CCL) received on 03/21/2023. LPA met with Administrator, Nellie Johnson, and explained the purpose of the visit.

During the course of investigation, the Department interviewed facility staff, residents in care, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, appraisal/needs and services plan, identification and emergency information, medication list, physician’s orders, medication administration records (MAR), staff trainings, fire clearance, employee roster, and resident roster.

Continue on page LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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
03/21/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20230321112340

FACILITY NAME:NELLIE'S ANGELS HOME CAREFACILITY NUMBER:
342700237
ADMINISTRATOR:NELLIE JOHNSONFACILITY TYPE:
740
ADDRESS:6730 SKYLANE DRIVETELEPHONE:
(916) 729-7648
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95621
CAPACITY:9CENSUS: 9DATE:
09/21/2023
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator: Nellie JohnsonTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Unlawful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced on 09/21/2023 to deliver complaint finding. LPA met with administrator, Nellie Johnson. The Department interviewed administrator and obtained pertinent documents relevant such as, resident’s (R1) physician’s report, physician’s orders, and fire clearance inspection. According to complainant, the facility evicted R1 due to non-ambulatory status and did not give R1 a 30-day notice. The facility’s fire safety inspection indicates that the facility is approved for 9 non-ambulatory residents. Doctor’s orders stated R1 is bedridden as last documented in R1’s chart on 8/26/2022. The facility does not have a fire clearance for bedridden residents. Administrator did not provide a 30-day notice to R1. Administrator stated there was a verbal agreement between the facility and RP to relocate R1 to a different facility. Based on records review and interviews, the allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
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-20230321112340
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: NELLIE'S ANGELS HOME CARE
FACILITY NUMBER: 342700237
VISIT DATE: 09/21/2023
NARRATIVE
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Allegation - Staff not administering resident's medication as prescribed. - Unsubstantiated.
The Department interviewed facility staff, residents in care, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) physician’s report, appraisal/needs and services plan, medication list, physician’s orders, medication administration records (MAR). The Department reviewed R1’s medication records for January 2022- October 2022. Medication records indicated, R1 did not receive medication Quetiapine on 7/31/2022. According to physician’s order, Quetiapine is to be given 1 tablet by mouth everyday at bedtime. Interview statement received from administrators, Nellie and Stephanie, indicated R1 was receiving all of R1's medication. R1 has never refused medication. Administrator Stephanie stated Quetiapine was given to R1 but administrator forgot to sign off on the medication log.

The Department interviewed a total of 2 residents in care. Interview statement received from residents indicated staff are consistently assisting residents with their medications. The Department conducted medication count for two (2) residents in care. Medications are centrally stored, locked, and appear to be given per doctor order. LPA compared medications to those being given for 2 residents and found no discrepancies. Complaint was filed against the facility on 3/21/2023. The Department was unable to conduct R1's medication count with the facility for R1's July 2022 medications. The Department is unable to determine if medication was provided to R1.

Allegation - Facility does not have enough staff to meet the needs of residents in care. – Unsubstantiated.

According to interviews conducted, there is one (1) staff per nine (9) residents. The Department requested and reviewed R1’s physician’s report, appraisal, and service plan. According to R1’s physician’s report, R1’s primary diagnosis is Dementia. R1 has bowel, bladder, and motor impairment. R1 needs assistance with bathing, dressing/grooming, feeding, toileting, and medication.

According to personnel Report (LIC 500), the facility staff consists of two (2) administrators and three (3) caregivers. Interview received from administrator, Stephanie Reid, indicated there are 2 caregivers working from 6AM to 6PM and 1 staff working from 6PM to 6AM. Interview statement received from administrator, Nellie Johnson, indicated that R1 needed 1:1 care and the facility had provided that for R1. Administrators are the ones who are providing care to residents with higher level of care. R1 had a change of condition. R1 was receiving wound care by a specialist for bed sore. Bed sore was healing. The main concern was that R1 was bending over while using the bathroom and the wound. Administrator contacted R1’s PCP due to R1 having muscle stiffness. PCP notified administrator the cause of R1 bending over is due to neurological or from nerve. Administrator provided records of the facility’s communication with R1’s RP.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20230321112340
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: NELLIE'S ANGELS HOME CARE
FACILITY NUMBER: 342700237
VISIT DATE: 09/21/2023
NARRATIVE
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The Department interviewed a total of three (3) facility staff who indicated there is sufficient staffing to meet the needs of residents in care. The Department interviewed two (2) residents in care. Residents indicated staff are meeting their needs.

Allegation - Staff did not provide adequate food service to resident in care. Unsubstantiated.

According to complainant, the facility fed R1 puree food and liquid foods for over a year. Facility was providing R1 with a gram of liquid ensure which is not sustainable. R1 was losing a lot of weight and the facility did not keep records of R1’s weight. The facility did not receive doctor’s orders for liquid foods.

The Department reviewed R1’s physician’s order. Physician’s order indicated to change R1’s diet to full liquids. “May try soft foods/puree as tolerated. R1 is not allowed to have rice, corn, lettuce, raw veggies, bread, and dry foods such as, popcorn, peanuts, and chips. The Department interviewed a total of four (4) facility staff. Interview statement received from staff were consistent. R1 was provided with liquid ensure, yogurt, Jell-o, pudding, Mac & Cheese, spaghetti, fruits, vegetables, mash potatoes, and more. Staff indicated R1 was receiving about 2-3 liquid ensure per day along with 3 meals a day. The Department received and reviewed R1’s care log. The facility’s care log was written by staff to indicate what services were provided to R1 from 6/14/2022 through 10/03/2022.

R1’s care logs indicated R1 was receiving meals and ensure between meals for snacks. Interview statement received from administrator, Nellie Johnson, indicated there was no physician’s order to weigh R1. Staff indicated, R1 had remained at a steady weight and did not observe R1 losing weight. LPA toured the facility to ensure that the facility was providing adequate food service to residents in care and observed food supplies of non-perishables for a minimum of one (1) week and perishable foods for a minimum of two (2) days. The Department interviewed a total of two (2) residents in care. Interview statements received from residents indicated meals are provided to all residents in care three times a day and snacks in between.

Allegation - Facility staff was not adequately trained.

The Department requested for three (3) staff’s training records for review. Staff has training in dementia care, medications, first aid and CPR, and other various areas of care provision. There are no records of staff training for food service. Interview statement from two (2) staff indicated that staff were provided food service training from administrator, Nellie Johnson. Staff stated staff were provided video training and online training on special diets.

The Department finds the allegations to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are unsubstantiated.



Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4