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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700506
Report Date: 07/20/2021
Date Signed: 07/20/2021 12:17:33 PM



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 Melana Llopis
COMPLAINT CONTROL NUMBER: 27-AS-20210326083547
FACILITY NAME:KENTFIELD ESTATES RANCH RCFEFACILITY NUMBER:
342700506
ADMINISTRATOR:SOUMAHORO, MARIAM GBATYFACILITY TYPE:
740
ADDRESS:3800 SILVER SPUR WAYTELEPHONE:
(916) 904-0027
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 5DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Mariam Gbaty SoumahoroTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident AWOLed due to neglect and lack of supervision.
Facility issued unlawful eviction of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 07/20/2021 to deliver complaint findings for a complaint the Department received on 03/26/2021. LPA met with Administrator, Mariam Gbaty Soumahoro and explained the purpose of the visit. Prior to the 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

Throughout the course of the investigation, the Department conducted interviews, obtained and reviewed documentation pertinent to the allegations listed above.
The results are as follows:

***Continuation on LIC-9099C***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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 5
Control Number 27-AS-20210326083547
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: KENTFIELD ESTATES RANCH RCFE
FACILITY NUMBER: 342700506
VISIT DATE: 07/20/2021
NARRATIVE
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Allegation: Resident AWOLed due to neglect and lack of supervision
The Department received a complaint on 03/26/2021 alleging resident (R1) eloped the facility due to staff neglect and lack of supervision. On 07/14/2021 and 07/15/2021 LPA spoke with Administrator who stated on 03/23/2021 R1 eloped the facility. Administrator stated staff did not go after resident because there were three (3) other residents in the home to tend to and R1 was acting aggressive toward staff. Administrator stated staff (S1) called R1's family and the local law enforcement. Administrator stated R1 was found in the morning at their father's house the following day. On 07/15/2021 LPA reviewed R1's resident file. Though Administrator stated to LPA that R1 had known elopement behavior, R1's needs and service plan did not address how staff will ensure safety of resident if resident tries to elope the facility. This allegation is found to be SUBSTANTIATED.

Allegation: Facility issued unlawful eviction of resident

The complaint alleged the facility did not accept resident (R1) back into the facility after their elopement on 03/23/2021. LPA interviewed Administrator on 07/14/2021 and 07/15/2021 who stated they did not agree to take back R1 after R1's elopement on 03/23/2021 due to unknown COVID-19 exposure. Administrator confirmed a written notice was not provided to R1 or their representative. This allegation is found to be SUBSTANTIATED.

Due to the above information the Department finds the allegations listed above to be SUBSTANTIATED meaning the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies being cited can be found on LIC-9099-D, per California Code of Regulations, title 22.

Exit interview conducted, copy of report and appeal rights provided.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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 Melana Llopis
COMPLAINT CONTROL NUMBER: 27-AS-20210326083547

FACILITY NAME:KENTFIELD ESTATES RANCH RCFEFACILITY NUMBER:
342700506
ADMINISTRATOR:SOUMAHORO, MARIAM GBATYFACILITY TYPE:
740
ADDRESS:3800 SILVER SPUR WAYTELEPHONE:
(916) 904-0027
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 5DATE:
07/20/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Mariam GbatyTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff do not serve nutritional food
Staff speak harshly to residents
Facility failed to issue a refund
False claims
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 07/20/2021 to deliver complaint findings for a complaint the Department received on 03/26/2021. LPA met with Administrator, Mariam Gbaty and explained the purpose of the visit. Prior to the 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; contacted licensee and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Masks.

Throughout the course of the investigation, the Department conducted interviews, obtained and reviewed documentation pertinent to the allegations listed above.
The results are as follows:

***Continuation on LIC-9099C***
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20210326083547
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: KENTFIELD ESTATES RANCH RCFE
FACILITY NUMBER: 342700506
VISIT DATE: 07/20/2021
NARRATIVE
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Allegation: Staff do not serve nutritional food
Complaint alleged the facility staff was not serving nutritious meals to residents in care.
On 07/08/2021 LPA reviewed facility menu and pictures provided by Administrator of resident meals. LPA observed the facility to provide three (3) meals a day with two (2) snacks in between. LPA observed meals to consist of fruits and vegetables as well as protein and healthy starches. LPA spoke with two (2) of two (2) residents on 07/08/2021 who stated the food was good. Residents did not state they had issues with food. No further evidence could be provided. LPA finds the allegation to be UNFOUNDED.

Allegation: Staff speak harshly to residents
Complaint alleged staff (S1) yells and is rude to residents in care. LPA spoke with two (2) of two (2) residents in care on 07/08/2021. Residents stated the staff treat them fine. Residents stated they did not hear yelling. LPA spoke with Home Health Nurse on 07/08/2021 who stated their patient did not voice any concerns with his care and is happy with his care. LPA interviewed staff and Administrator on 07/08/2021 and 07/15/2021 who stated staff do not yell at residents.
No further evidence could be provided. LPA finds the allegation to be UNFOUNDED.

Allegation: Facility failed to issue a refund
Complaint alleged the facility did not issue a refund to R1 after being evicted. On 07/08/2021 LPA spoke with R1's placement agent who stated they received confirmation from R1's representative that R1 did receive a full refund in April 2021, the same month R1 left the facility. LPA finds the allegation to be UNFOUNDED.

Allegation: False claims
On 07/08/2021, LPA interviewed two (2) of two (2) residents in care who did not report facility providing false statements to residents. LPA spoke with key witnesses who did not believe the facility was providing false statements or claims. No information or evidence could be provided by key witnesses that facility is providing false claims. LPA finds allegation to be UNFOUNDED.

Based on interviews, records review and facility visit observations, LPA finds the allegation(s) listed above to be UNFOUNDED meaning

Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20210326083547
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: KENTFIELD ESTATES RANCH RCFE
FACILITY NUMBER: 342700506
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2021
Section Cited
CCR
87705(a)(4)
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87705 Care of Persons with Dementia
(a) This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia. Mild cognitive impairment, as defined in Section 87101(m), is not considered to be dementia.
(4) There is an adequate number of direct care staff to support
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Licensee understands the importance of ensuring there are adequate staff to support each resident's specific needs.
Licensee stated R1 is no longer residing at the facility. Licensee agrees to send to CCL their new plan to accommodate the needs of residents with elopement behavior. Licensee to send this plan to CCL by POC date provided.
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each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
This requirement was not met as evidenced by:
R1 eloped the facility on 03/23/2021 and there was not a staff member available to ensure R1's safety.
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Type A
07/21/2021
Section Cited
CCR
87224(a)
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87224 Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).
This requirement was not met as evidenced by:
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Licensee stated R1 is living with their family. Moving forward, Licensee agrees to review regulation 87224 Eviction Procedures in its entirety and send CCL a letter of understanding by the POC date provided.
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The Licensee evicted R1 without providing R1 with a written thirty (30) day notice. This immediately put R1's safety and personal rights at risk.
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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: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5