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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700506
Report Date: 08/30/2021
Date Signed: 08/30/2021 01:52:11 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
07/01/2021 and conducted by Evaluator Melana Llopis
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210701113651
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: 4DATE:
08/30/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Mariam Gbaty SoumahoroTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not adequately supervising residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 08/30/2021 to deliver findings for a complaint the Department received on 07/01/2021. Prior to 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; upon visit completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Paula McDonald, staff, upon entering the facility.
LPA met with Administrator, Mariam Gbaty and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted multiple interviews, toured the facility and reviewed documentation pertinent to the investigation.

Results are as follows:

***Continuation on LIC9099C***
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: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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 7
Control Number 25-AS-20210701113651
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: 08/30/2021
NARRATIVE
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Allegation: Staff are not adequately supervising residents

Complaint alleged facility staff are locking residents in their bedrooms to substitute for adequate supervision. On 07/08/2021 LPA conducted an unannounced visit to the facility and found the outer gate to be locked. LPA called the facility and staff (S1) opened the gate for LPA to enter. LPA spoke with S1 who stated the gate is locked because residents in the home have mental impairments which cause wandering. LPA spoke with Administrator during time of visit, who stated the facility did not have a waiver for the exterior gate to be locked. LPA requested to review resident's needs and service care plans. LPA reviewed a sample of two (2) of two (2) residents' needs and service plans. LPA did not find a plan in place to address resident wandering.

Based on the information above, LPA finds the allegation to be SUBSTANTIATED,meaning the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D.

Exit interview conducted, copy of report provided.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
07/01/2021 and conducted by Evaluator Melana Llopis
COMPLAINT CONTROL NUMBER: 25-AS-20210701113651

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: 4DATE:
08/30/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Mariam Gbaty SoumahoroTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Residents are locked in their rooms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 08/30/2021 to deliver findings for a complaint the Department received on 07/01/2021. Prior to 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; upon visit completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Paula McDonald, staff , upon entering the facility.
LPA met with Administrator, Mariam Gbaty and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted multiple interviews, toured the facility and reviewed documentation pertinent to the investigation.

Results are as follows:

***Continuation on LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
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 7
Control Number 25-AS-20210701113651
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: 08/30/2021
NARRATIVE
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Allegation: Facility staff are locking residents in their rooms.

Complaint alleged facility staff are locking residents in their bedrooms to substitute for adequate supervision. On 07/08/2021 LPA conducted an unannounced visit to the facility and found the outer gate to be locked. LPA called the facility and staff (S1) opened the gate for LPA to enter. LPA spoke with S1 who stated the gate is locked because residents in the home have mental impairments which cause wandering. LPA spoke with Administrator during time of visit, who stated the facility did not have a waiver for the exterior gate to be locked. LPA requested to review resident's needs and service care plans. LPA reviewed a sample of two (2) of two (2) residents' needs and service plans. LPA did not find a plan in place to address resident wandering. No further evidence could be provided.

Based on the information above, LPA finds the allegation to be UNSUBSTANTIATED, meaning 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, and the findings are unsubstantiated.

An exit interview was conducted. No deficiencies were cited on today’s date. Appeal rights provided.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
07/01/2021 and conducted by Evaluator Melana Llopis
COMPLAINT CONTROL NUMBER: 25-AS-20210701113651

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: 4DATE:
08/30/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Mariam Gbaty SoumahoroTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff are not adequately trained.
Staff are over medicating residents.
Staff are not administering medications as prescribed.
Facility is malodorous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melana Llopis arrived at the facility unannounced on 08/30/2021 to deliver findings for a complaint the Department received on 07/01/2021. Prior to 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; upon visit completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Paula McDonald, staff , upon entering the facility.
LPA met with Administrator, Mariam Gbaty and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted multiple interviews, toured the facility and reviewed documentation pertinent to the investigation.

Results are as follows:

***Continuation on LIC9099C***
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 25-AS-20210701113651
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: 08/30/2021
NARRATIVE
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Allegation: Staff are not adequately trained.
Complaint alleged staff (S2) does not have adequate training. LPA reviewed S2's training on 07/09/2021 and found S2's training was current and adequate. LPA spoke with Administrator on 07/08/2021 who stated S2 was trained, however S2 did not meet facility's standards for the position. Administrator stated S2 was not accountable, therefore S2's employment was terminated. Allegation is UNFOUNDED.

Allegation: Staff are over medicating residents.
LPA conducted a medication audit for a sample of two (2) of two (2) residents in care. LPA did not observe errors upon audit.
On 07/08/2021, LPA interviewed two (2) of two (2) residents in care. Residents stated they receive their medications and did not have problems with getting their medications. Allegation is UNFOUNDED.

Allegation: Staff are not administering medications as prescribed.
LPA conducted a medication audit for a sample of two (2) of two (2) residents in care. LPA observed no errors.
On 07/08/2021, LPA interviewed two (2) of two (2) residents in care. Residents stated they did not have issues with their medications. Allegation is UNFOUNDED.

Allegation: Facility is malodorous.
LPA visited the facility on 07/08/2021 and observed the facility to be clean and free of foul odor. LPA spoke with two (2) of two (2) residents in care who stated the facility is kept clean and does not smell. LPA spoke with staff (S1) who stated the facility is kept clean and does not have a foul smell. LPA spoke with a key witness who stated the facility did not have a foul smell during their visits. Allegation is UNFOUNDED.

Due to the information above, the Department finds the allegations to be 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, copy of report provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 25-AS-20210701113651
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: 08/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/31/2021
Section Cited
CCR
87705(I)(6)
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87705 Care of Persons with Dementia
(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (6) Locked exterior doors or perimeter fences with locked gates shall not substitute
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Licensee unlocked fence during initial visit when LPA found the outer fence to be locked. LIcensee understands the perimeter fence needs to remain unlocked wihtout a proper waiver Licensee agrees to submit a detailed plan of action that will include the faciltiy staff plan to ensure the safety of residents who are wander risks.
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 for trained staff in sufficient numbers to meet the care and supervision needs of all residents.
This requirement was met as evidenced by:
Licensee locked perimeter fensces to assist with supervising residents who wander in the community. This put an immediate personal rights risk to residents in care.
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Licensee will submit plan to CCL by POC date provided.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melana LlopisTELEPHONE: 510-298-7052
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7