342700535-4-27-2021-25-AS-MSEY-C2HL4K-20210428082538

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700535
Report Date: 04/23/2021
Date Signed: 04/27/2021 04:06:08 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
04/23/2021 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20210423110223

FACILITY NAME:	SPLENDOR OF CARMICHAEL AT PALM, THE		FACILITY NUMBER:	342700535
ADMINISTRATOR:	FOGGY, BRUCE		FACILITY TYPE:	740
ADDRESS:	2839 CALIFORNIA AVE		TELEPHONE:	(916) 514-9421
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 3	DATE:	04/23/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Bruce Foggy, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Residents left unattended

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada contacted the facility Administrator, Bruce Foggy, by phone to conduct the 10-day inspection due to current Covid-19 precautionary measures in place. LPA explained the purpose of the call.

LPA discussed the allegation with Administrator on 4/23/2021 who confirmed that staff (S1) left the facility at approximately 10:00 am on 4/23/2021 and there was no staff present with the residents for approximately (1) hour, until 11:00 am when he arrived. Administrator stated he received a text message from S1 around 10:00 am stating she had to leave the facility immediately due to a family emergency. Administrator did not have any additional details to provide. Administrator confirmed that there were (3) residents present today, along with two family members who were visiting a resident, when S1 left the facility. A related case management inspection was conducted yesterday, 4/22/2021, concerning facility staffing levels.

Based on information obtained, LPA finds the above allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

The following (1) deficiency is being cited on the 9099C page as well as an immediate civil penalty in the amount of $500.00 due to an absence of supervision.

Exit interview. Copy of report, civil penalty and appeal rights to be emailed to Administrator who agrees to return a signed copy to the department by 5:00 pm today, 4/23/2021.

Substantiated

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: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

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-20210423110223

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 PALM, THE	FACILITY NUMBER: 342700535
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 04/24/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator arrived at the facility on 4/23/2021 @ approximately 11:00 am and remained on site. Another staff member arrived at 11:35 am approximately while LPA was on the phone with Administrator. Administrator agrees to provide a completed LIC500 (Personnel Report) to CCLD by 4/24/2021 by fax to show current staffing levels/hours. Administrator to hold staff meeting by Tuesday, 4/27/2021, to explain responsibilities of staff and send documentation of agenda/attendees to CCLD by fax by 4/27/2021.
	8 9 10 11 12 13 14	Based on interview with Administrator, the facility did not ensure that there was at least (1) staff member present with the residents on 4/23/2021 for approximately one hour, from 10:00 am- 11:00 am, which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

LIC9099 (FAS) - (06/04)

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