342700284-2-2-2021-27-AS-KHOS-BXWMAC-20210204082607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700284
Report Date: 02/02/2021
Date Signed: 02/02/2021 02:54:12 PM

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
07/10/2020 and conducted by Evaluator Bethany Huusfeldt

COMPLAINT CONTROL NUMBER: 27-AS-20200710163358

FACILITY NAME:	MINNESOTA HOME CARE		FACILITY NUMBER:	342700284
ADMINISTRATOR:	OKYERE, VERA		FACILITY TYPE:	740
ADDRESS:	7448 MINNESOTA DRIVE		TELEPHONE:	(916) 842-9025
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	0	CENSUS: 0	DATE:	02/02/2021
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	HENRIETTA A. DONKOR, Licensee		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident developed a Stage 2 pressure injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Huusfeldt spoke to licensee Henrietta Donkor to deliver findings in complaint investigation. LPA conducted the visit over the phone due to COVID precautions.

The department investigated the allegation of “Resident developed a Stage 2 pressure injury while in care”. The department reviewed facility documents, conducted interviews with facility staff and residents. It was reported to CCL R1 was examined by a health care professional upon admission into the facility in June 2020 and no ulcers were observed. R1 was reexamined in July 2020 and the health care professional observed a stage 2 ulcer on R1’s right heel and a stage 3 ulcer on R1's left heel. The department interviewed facility staff and licensee.
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: 02/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021

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-20200710163358

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: 02/02/2021

NARRATIVE

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Licensee examined R1 on the day of admission to the facility. Licensee observed 1 sore on resident's heel, however it was almost healed and no infection was present. Staff stated they provide consistent care to all residents. The department interviewed 3 residents at the facility, and all three residents stated their needs were being met. The department was unable to obtain VA medical records, and unable to verify if resident had a stage-able ulcer. Due to the information gathered, LPA finds allegation to be unsubstantiated.

A finding that the complaint 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.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021

LIC9099 (FAS) - (06/04)

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