342700777-10-13-2021-25-AS-MSEY-C7SSF9-20211014134956

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700777
Report Date: 10/13/2021
Date Signed: 10/13/2021 04:40:22 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
05/24/2021 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 25-AS-20210524115113

FACILITY NAME:	SIGNATURE LIVING ON WINDING WAY II		FACILITY NUMBER:	342700777
ADMINISTRATOR:	AFABLE, SCOTT		FACILITY TYPE:	740
ADDRESS:	6270 WINDING WAY		TELEPHONE:	(916) 812-0944
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	10/13/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Zeny Young, Caregiver		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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-Staff physically abusing resident.
-Staff did not properly feed resident

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Angela Hood and Michael Hood arrived at the care home today and met with caregivers to deliver findings into the allegations listed above. Administrator stated that caregiver can sign report during today's visit. Facility currently does not have any COVID-19 positive cases. LPAs wore N95 masks and were screened by facility upon entry. Facility staff wore a mask in the care home.

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Interviews conducted with residents (R1 and R4) indicated that they have never felt threatened by staff or witnessed staff mistreating residents in care. Interviews with R1 and R4 indicated that they have no concerns with the care home. Interview with R1 indicated that R1 has no issues being fed by staff and has never had any issues with eating. Interview with R4 indicated that the facility feeds them well.

***********************************************Continued on LIC9099-C****************************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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-20210524115113

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: SIGNATURE LIVING ON WINDING WAY II	FACILITY NUMBER: 342700777
	VISIT DATE: 10/13/2021

NARRATIVE

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Interview with outside agency personnel indicated that they spoke with R1 and that R1 has not experienced abuse from staff at the care home.

Interviews with staff (S1 and S2) indicated that R1 and R2 require assistance during mealtime. Interview with S1 indicated that R1 requires assistance during mealtime when eating with a utensil and that R1 can eat hand held food on their own. Interviews with S1 and S2 indicated that they have never witnessed staff being aggressive or rough with residents during mealtime. Interviews indicated that S1 and S2 have never witnessed staff being physically or verbally abusive to residents in care. Interview with staff (S4) indicated that they have not observed any signs of abuse with residents in care.

Training documentation was obtained for S1, S2, and S3, which indicated that they have all been trained during an annual training conducted in 2021 for Importance and Techniques of Personal Care, which includes feeding residents.

R1's Preplacement Appraisal dated 7/21/20 indicates that R1 has a regular diet, requires help with eating on occasion, and with meal set-up. R1's Physician's Report LIC602A indicates that R1 does not require a special diet and is able to feed self.

Based on interviews conducted and documentation obtained, 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 with Administrator via phone.

SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Angela Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

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