342700531-10-5-2022-25-AS-KHOS-CK3N8G-20221010101417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700531
Report Date: 10/05/2022
Date Signed: 10/05/2022 02:22:19 PM

Unfounded

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
09/02/2022 and conducted by Evaluator Jacob Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220902150607

FACILITY NAME:	A1 MAGNIFICENT HOME		FACILITY NUMBER:	342700531
ADMINISTRATOR:	GAERLAN, LEONIDA		FACILITY TYPE:	740
ADDRESS:	3311 MISSION AVENUE		TELEPHONE:	(916) 335-5831
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	5	CENSUS: 2	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Leonida Gaerlan		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility staff slapped resident in care
Facility staff handled resident in an inappropriate manner
Facility staff spoke inappropriately to resident in care

INVESTIGATION FINDINGS:

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LPA Williams arrived on Wednesday October 5, 2022 to conclude a complaint investigation regarding the following allegations: Facility staff slapped resident in care, facility staff handled resident in an inappropriate manner, and facility staff spoke inappropriately to resident in care.

Prior to the visit, LPA completed the 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 she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

LPA Williams spoke with Administrator Leonida Gaerlan and expained the findings. Throughout the course of the investigation, LPA interviewed staff and residents.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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 25-AS-20220902150607

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: A1 MAGNIFICENT HOME	FACILITY NUMBER: 342700531
	VISIT DATE: 10/05/2022

NARRATIVE

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Additionally, LPA reviewed R1’s admission agreement, progress notes, physicians report and staff notes. R2 was the only other resident residing at A1 Magnificent Home, states that they have never seen staff be verbally or physically abusive to the resident, but has witnessed the resident be abusive to staff on many occasions. R1 was dealing with a well-documented substance abuse problem which has led to mood swings and outbursts. In addition, R1 recently returned to A1 Magnificent Home after living in a SNF briefly, and upon return R1 stated that the allegations are untrue, that he doesnt know who filed the allegations.

Based on LPAs interviews and review of documentation, the preponderance of evidence standards was not met, therefore, the above allegations are found to be UNFOUNDED. An unfounded allegation means that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted. A copy of this report emailed to Administrator.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Jacob Williams	TELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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