342700531-10-13-2023-59-AS-MSEY-CWPNX2-20231017105024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700531
Report Date: 10/11/2023
Date Signed: 10/13/2023 04:07:54 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/21/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230921152717

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:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Enrique Gaerlan, Caregiver		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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-Staff is allowing resident to smoke where oxygen is in use.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 10/11/23, and met with the caregiver to deliver findings into the allegation of staff are allowing resident to smoke where oxygen is in use.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation.

Interview with the Administrator and staff (S1) indicated that they do not encourage or allow resident (R1) to smoke while using oxygen. The Administrator indicated that they have put a sign on the door of R1's room as a reminder to not use oxygen when smoking outside. LPA observed the reminder sign and the oxygen in use signs in R1's room. Interview with R1 indicated that they do not use oxygen while smoking. R1 stated that they have forgotten a couple times but the Administrator and S1 always remind R1 to not use oxygen while smoking.
************************************************Continued on LIC9099-C***************************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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 59-AS-20230921152717

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: A1 MAGNIFICENT HOME	FACILITY NUMBER: 342700531
	VISIT DATE: 10/11/2023

NARRATIVE

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Unusual Incident/Injury Report LIC624s submitted to CCL dated 9/2/22 and 3/23/23 indicated two incidents of R1 being found by staff using oxygen while smoking. The LIC624s indicated that staff will continue to closely monitor R1 to ensure they do not use oxygen while smoking. Staff will also continue to monitor R1's oxygen level.

Eviction notice provided to LPA dated 8/1/23 indicated that R1 is being evicted due to noncompliance with house rules, which indicated smoking in room after constant reminders not to and smoking with oxygen on after constant reminders not to. Interviews with the Administrator, S1, and R1 indicated that R1 will be moving out of the care home to another facility soon.

On 9/26/23, LPA did not observe R1 as they were at the hospital. On 10/11/23, LPA did not observe R1 using oxygen while smoking.

Based on observation, interviews conducted, and documentation reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited during this visit.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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