342700559-6-28-2022-25-AS-KHOS-CG2PPH-20220705112933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700559
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:24:01 PM

Unsubstantiated

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
01/14/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20220114125754

FACILITY NAME:	CITRUS CREST CARE HOME		FACILITY NUMBER:	342700559
ADMINISTRATOR:	TICONUWU, HARRY		FACILITY TYPE:	740
ADDRESS:	6906 HENNING DR		TELEPHONE:	(916) 728-1338
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95621
CAPACITY:	0	CENSUS: 0	DATE:	06/28/2022
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Angie Chavez, Administrator		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not provide resident with a copy of Admissions Agreement

Facility did not assist with bathing

Facility did not assist with grooming

Staff did not assist with ambulating

Staff did not allow resident privacy to make phone calls

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/28/2022, Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Angie Chavez, to conclude a complaint investigation into the allegations listed above. LPA wore an N-95 mask and was screened by facility upon entry. Facility staff wore masks while on the premises.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility did not provide resident with a copy of Admissions Agreement

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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 3

Control Number 25-AS-20220114125754

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: CITRUS CREST CARE HOME	FACILITY NUMBER: 342700559
	VISIT DATE: 06/28/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interview with Administrator, Mariam Soumahoro, indicated that they provided a copy of the Admission Agreement to resident (R1) and has a copy of R1’s Admission Agreement in R1's facility file. In addition, Administrator Soumahoro provided a signed copy of the agreement to the licensing agency.

Interview with resident (R2) indicated that R2 has a copy of their Admission Agreement on hand, but could ask to see their papers from the facility staff if they needed to. Interview with resident (R3) indicated that they have no concerns regarding the facility.

Allegation: Facility did not assist with bathing

Physician’s Reports for the residents in care indicated that some residents receive assistance “as needed” regarding bathing and other residents require assistance with bathing.

Interview with R2 indicated that they are sufficiently receiving assistance with all of their care needs from staff. Interview with resident (R4) indicated that they receive care from hospice nurses, but facility staff treat them well. Interview with staff member (S1) indicated that hospice aides come to assist with bathing and grooming for resident (R4), but stated they may help hospice aides with care services for R4. Interview with Administrator Soumahoro indicated that R1 would get assistance with bathing if requested, however, R1 is capable of bathing themselves.

Allegation: Facility did not assist with grooming

Physician’s Reports for the residents in care indicated that some residents receive assistance “as needed” regarding grooming and other residents require assistance with grooming.

R2 stated that they receive a little assistance changing clothes from staff. Interview with Administrator Soumahoro indicated that R1 was capable of grooming themselves, however, R1 would be provided assistance if requested.

** Report continued on 9099-C **

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20220114125754

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: CITRUS CREST CARE HOME	FACILITY NUMBER: 342700559
	VISIT DATE: 06/28/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff did not assist with ambulating

Physician’s Reports for the residents in care indicated that some residents receive assistance “as needed” regarding ambulating and other residents require assistance with ambulating.

R2 stated that they do not need assistance with ambulating. S1 stated that R3 needs assistance with ambulating, which S1 provides assistance with. Interview with Administrator Soumahoro indicated that R1 is capable of ambulating on their own, however, assistance would have been provided if needed.

Allegation: Staff did not allow resident privacy to make phone calls

It was reported that residents are allowed to use their own cellular telephone or the facility phones to make private calls. It was reported that there was an incident regarding R1 continually calling 911, which lead to 911 blocking the facility number. Interview with Administrator Soumahoro indicated that they began offering assistance with R1's calls after 911 blocked the facility's number.

R2 stated that they are able to talk on the phone in private. S1 stated that residents at the facility have their own phones, but a phone is available for the residents to use and residents are able to use the phone in private.

Based on interviews conducted by the Department and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3