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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700535
Report Date: 11/17/2021
Date Signed: 11/17/2021 02:56:51 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
04/16/2021 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210416152203
FACILITY NAME:SPLENDOR OF CARMICHAEL AT PALM, THEFACILITY NUMBER:
342700535
ADMINISTRATOR:FOGGY, BRUCEFACILITY TYPE:
740
ADDRESS:2839 CALIFORNIA AVETELEPHONE:
(916) 514-9421
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
11/17/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maria Williams, House Manager/Assistant Administrator and Bruce Foggy, Administrator TIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Audio alert on back door not working resulting in resident wandering out without staff noticing
INVESTIGATION FINDINGS:
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During the course of the investigation, the Department interviewed the Administrator, House Manager/Assistant Administrator, (3) caregivers, resident's (R1) responsible person, and attempted to interview (2) additional caregivers. Additionally, the Department reviewed documentation pertaining to resident (R1) including, but not limited to, physician's report, appraisal, needs and services plan, and a letter written by a caregiver. On 8/24/2021, LPA tested multiple exit door sensors and observed them to be working correctly.

The results of the investigation are as follows:

Administrator stated that he wasn't aware of resident (R1) ever being able to leave the facility unattended or through the door from resident's room to outside of the facility and confirmed that there have not been any prior or current issues with door alarms not functioning correctly. House Manager stated that it has never happened that resident (R1) was ever able to exit the facility without staff being aware and sensors have always worked and there has "never been an issue with any door". House Manager stated she would occasionally work during the night shift and would never go to sleep until 11:00 pm and would have known if R1 was able to exit to the outside from her bedroom door.

cont on 9099-C(1)...

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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 2
Control Number 25-AS-20210416152203
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
VISIT DATE: 11/17/2021
NARRATIVE
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9099-C (1)..Interview with a prior caregiver indicated that another caregiver stated to them that resident (R1) was able to leave through the exit door in her room to the outside of the facility, stating "it happened in the night but I'm nor exactly sure what time". The same caregiver explained that R1 was able to open the door and exit, and the exit door "could not be locked since it was marked as an emergency exit", but was not sure why. The caregiver added "If anything happened, Maria would know about it" and that the incident was reported to management. The interview revealed that R1 "was having trouble sleeping and the doctor had to increase the sleeping meds- it was either just prior to the incident or right after the incident", explaining R1 would get up at night as she was agitated and confused and she would usually go in the hallway". The same interview revealed that R1 never went out the door while they were on duty and there were no issues with any door alarms with the caregiver stating "only Bruce, Maria and Martha" knew where to assess the alarm- I didn't know where to turn it on and off".

LPA Interviewed (2) current caregivers on 8/24/2021 who stated they had never met R1, who moved out prior to them starting to work at the facility approximately (4) months ago. LPA attempted to contact (2) prior caregivers, multiple times, for additional information and was not able to. LPA reviewed a hand-written letter provided to the Department from a prior caregiver who indicated that they "found R1 outside the premises late in the night". No details of day and/or time are indicated in the letter; however, the letter additionally states "the door locks were not good and the door locks would not be locked up in the nights". Administrator clarified that all exit doors are locked from the outside but are not locked from the inside.

Based on information obtained during the investigation, the Department finds the allegation to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means 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.

Exit interview. Copy of report was provided via e-mail following the inspection.


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SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2