342700284-8-5-2020-27-AS-TORZ-BS8USN-20200806155035

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700284
Report Date: 08/05/2020
Date Signed: 08/05/2020 11:09:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/09/2020 and conducted by Evaluator Bethany Huusfeldt

COMPLAINT CONTROL NUMBER: 27-AS-20200309144920

FACILITY NAME:	MINNESOTA HOME CARE		FACILITY NUMBER:	342700284
ADMINISTRATOR:	DONKOR, HENRIETTA		FACILITY TYPE:	740
ADDRESS:	7448 MINNESOTA DRIVE		TELEPHONE:	(916) 842-9025
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 1	DATE:	08/05/2020
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Vera Okyere, Administrator		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility is not following residents special diet
Facility failed to ensure that oxygen administration was provided appropriately

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Huusfeldt delivered findings to allegations listed above. LPA spoke with administrator Vera Okyere over the phone. Due to COVID-19 precautions, LPA was unable to meet in person with administrator.
LPA investigated the allegation, "Facility is not following residents special diet". LPA toured the facility on 3/11/20 and 7/10/20 and inspected the food available to residents. LPA observed sufficient amount of food, and variety of foods including fruits and vegetables. LPA interviewed relevant party, staff, and health care clinicians. Interviews with relevant party indicate facility did not provide a diabetic diet for resident. Interviews with health care clinicians indicate they did not observe the food being provided to the resident. Staff interviews indicated they served resident the food they requested. Due to the conflicting information gathered, LPA finds allegation to be unsubstantiated.
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

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

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200309144920

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MINNESOTA HOME CARE	FACILITY NUMBER: 342700284
	VISIT DATE: 08/05/2020

NARRATIVE

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LPA investigated allegation, "Facility failed to ensure that oxygen administration was provided appropriately". LPA interviewed relevant party, health care clinicians, and facility staff. Interviews with relevant party indicate they observed resident's oxygen turned off and not working during a visit. Interviews with health care clinicians stated they observed the oxygen to be working, turned on, and on the resident when they visited. Interviews with facility staff stated resident always had her oxygen on and working. Due to the conflicting information gathered LPA finds the allegation to be unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Administrator to return a signed copy of the report to CCL within 10 days.

Exit interview conducted and copy of report provided.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2020

LIC9099 (FAS) - (06/04)

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