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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700370
Report Date: 07/02/2021
Date Signed: 07/02/2021 11:49:21 AM



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
03/26/2021 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 27-AS-20210326112359
FACILITY NAME:PRAIRIE CITY LANDINGFACILITY NUMBER:
342700370
ADMINISTRATOR:MARTIN, CHERYL KFACILITY TYPE:
740
ADDRESS:645 WILLARD DRTELEPHONE:
(916) 458-0303
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:200CENSUS: 128DATE:
07/02/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cheryl Martin, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff inappropriately touched resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to deliver findings into allegation listed above. LPA met with Cherly Martin upon time of arrival. 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: Masks. Additionally, LPA was screened by staff, upon entering the facility.
The department investigated the allegation of “Facility staff inappropriately touched resident”. The department conducted file reviews, and interviewed staff, residents, and relevant parties. Relevant party reported that staff inappropriately touched R1 when continence care was being provided.
Continuation on 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
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 3
Control Number 27-AS-20210326112359
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: PRAIRIE CITY LANDING
FACILITY NUMBER: 342700370
VISIT DATE: 07/02/2021
NARRATIVE
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Relevant party stated care was being provided without gloves. Relevant parties’ statement was consistent when being interviewed by different agencies. Caregiver (C1) declined to be interviewed by the department, however a statement was received in which C1 denied inappropriately touching R1. Interviews were completed with R1, in which they stated they were uncomfortable in the way C1 was touching them during continence care. Due to the information gathered, the department finds allegation to be SUBSTANTIATED.

As a result of this investigation, LPA finds allegations 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: Refer to the 9099-D.

Exit interview conducted and appeal rights given.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210326112359
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: PRAIRIE CITY LANDING
FACILITY NUMBER: 342700370
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/05/2021
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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Administrator agrees to conduct a training with staff on proper PPE when performing care and resident rights. Administrator to send into LPA the date of the training and subject matter by 7/5/2021.
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This requirement is not met as evidenced by: Based on interviews resident was not accorded dignity in their personal relationships with staff which poses an immediate health and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021
LIC9099 (FAS) - (06/04)
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