342700534-2-16-2022-25-AS-MSEY-CBWVQE-20220223153814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700534
Report Date: 02/16/2022
Date Signed: 02/16/2022 05:02:23 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
01/05/2022 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220105105041

FACILITY NAME:	SPLENDOR OF CARMICHAEL AT KEANE, THE		FACILITY NUMBER:	342700534
ADMINISTRATOR:	FOGGY, BRUCE		FACILITY TYPE:	740
ADDRESS:	4921 KEANE DRIVE		TELEPHONE:	(916) 514-9173
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2022
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Shameik Williams, caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Residents not afforded dignity in their personal relationship to facility staff
Resident was not showered
Facility does not have soap

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conclude a complaint investigation and deliver findings to a complaint the Department received on 1/5/2022. LPA met with Shameik Williams, caregiver who contacted the House Manager, Maria Williams and Administrator, Bruce. Caregiver on site confirmed there are (6) residents currently, and there is (1) resident on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA observed (1) resident to be watching television on the couch in the front room and (5) residents to be napping/awake in their rooms.

During the course of the investigation, LPA interviewed Administrator, House Manager, (1) caregiver (S1), (3) residents and an Ombudsman, and reviwed resident's (R1) physician's report and care plan.

The results of the investigation are as follows:

cont on 9099C(1)...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

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-20220105105041

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: SPLENDOR OF CARMICHAEL AT KEANE, THE	FACILITY NUMBER: 342700534
	VISIT DATE: 02/16/2022

NARRATIVE

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9099C(1)..Allegation: Residents not afforded dignity in their personal relationship to facility staff. Resident (R1) stated that staff does not always listen to her concerns and her laundry was not placed in the dryer and acquired a mildew like smell. Caregiver stated every residents laundry is placed in the dryer after it is washed; however, one time last week, R1, tried to pull her socks from the washing machine before they were finished washing and then pulled them from the dryer before the drying cycle was completed.

R1 stated she does not know how facility staff treat other residents. Resident (R2) stated that he feels comfortable at the facility, has no complaints and "it is a very pleasant environment". Resident (R3) stated that facility staff are "very nice people" and will listen to her when she has a concern. R3 stated she has not seen staff treat residents disrespectfully. Facility staff stated that R1 has made derogatory comments to facility staff on many occasions. Interview with Long-Term Care Ombudsman indicated that R1 has contacted him on many occasions and may not be understanding everything clearly.

Based on information obtained, the Department finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Allegation: Resident was not showered. R1 indicated she was not able to take a shower for several days, on/around January 2022, due to the facility not having any soap. R1 stated to LPA she sometimes needs assistance with showers, such as staff handing her a towel. Physician Report for R1, dated 8/12/2021, indicates she needs assistance with showering. R1 stated usually there are blue bottles of shower wash kept in the shower, but they have not been there for the last few days and showed LPA, on 1/12/2022 where there are bottles in the laundry room. R1 also stated she gets cold easily in the bathroom as the heater doesn't work in the bathroom. House Manager stated to LPA that she told R1 that there is a body wash in a blue bottle in the shower. House Manager indicated staff needs to also remind resident to bring a towel when she showers. Both the House Manager and a caregiver stated that R1 has refused showers on many occasions recently and R1's daughter was notified by text message. Residents (R2/R3) stated they receive showers when they are scheduled and R2 stated he can get an extra shower, if needed. Administrator stated the facility does not keep shower documentation.

Based on information obtained, the Department finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

cont on 9099C(2)..

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220105105041

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: SPLENDOR OF CARMICHAEL AT KEANE, THE	FACILITY NUMBER: 342700534
	VISIT DATE: 02/16/2022

NARRATIVE

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9099C(2)...Allegation: Facility does not have soap.

R1 explained that she had not been able to get a shower for several days, on/around January 2022, due to no soap in the shower. R1 stated usually there are blue bottles of shower wash always kept in the shower, but they have not been there for the last few days and told LPA there are bottles in the laundry room. R1 also stated she gets cold easily in the bathroom as the vent doesn't work in the bathroom. House Manager stated that she stated to R1 that there is a body wash in a blue bottle in the shower. Both LPA and R1 observed a blue bottle of shower wash in the shower on 1/12/2022, at approximately 1:30 pm; R1 stated the bottle was not there earlier in the day. LPA observed soap to also be near sinks for hand-washing and observed other body cleansers stored in the laundry room. LPA observed the blue body wash to be in the shower on 2/16/2022 @ approximately 4:40 pm.

Based on information obtained, the Department finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview with Administrator, by phone, who authorized caregiver to sign reports. Copy of report left at facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

LIC9099 (FAS) - (06/04)

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