342700783-10-7-2021-25-AS-LMUZ-C7PUR6-20211011154813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700783
Report Date: 10/07/2021
Date Signed: 10/07/2021 03:28:52 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
09/20/2021 and conducted by Evaluator Michael Smith

COMPLAINT CONTROL NUMBER: 25-AS-20210920163411

FACILITY NAME:	7117 MAIN, LLC		FACILITY NUMBER:	342700783
ADMINISTRATOR:	GLADYS GASTA		FACILITY TYPE:	740
ADDRESS:	7117 MAIN AVE		TELEPHONE:	(707) 592-4004
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	6	CENSUS: 6	DATE:	10/07/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Juliet Irungu		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not following physicians orders for medication administration

INVESTIGATION FINDINGS:

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

Prior to entering the facility, LPA Smith spoke with staff to pre-screen that the facility is COVID free. Analyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening protocols, wore a mask and maintained distance during the visit. LPA Smith conducted an unannounced complaint visit and met with Juliet Irungu.

Complaint alleges that the resident was only administered 1/2 the dosage as the prescription states. Based on witness interviews, LPA was unable to confirm this allegation.

As a result of this investigation, LPA finds the allegation that staff are not following physicians orders for medication administration 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Michael Smith	TELEPHONE: (916) 208-7807
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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 3