342700792-5-19-2021-25-AS-MSEY-C37V3W-20210520160526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700792
Report Date: 05/19/2021
Date Signed: 05/19/2021 10:47:25 AM

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 Bethany Huusfeldt

COMPLAINT CONTROL NUMBER: 25-AS-20210423124730

FACILITY NAME:	AMERICAN RIVER RESIDENTIAL CARE, LLC		FACILITY NUMBER:	342700792
ADMINISTRATOR:	SU, JOLENE SOI		FACILITY TYPE:	740
ADDRESS:	124 HILLSWOOD DRIVE		TELEPHONE:	(916) 716-5431
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	6	CENSUS: 3	DATE:	05/19/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jolene Soi Su, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff not following physician's orders for proper irrigation of resident's catheter.
Facility does not have non-slip protective devices on resident's bathroom floor.
Food service requirements are not being met by facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Huusfeldt Mirlohi arrived unannounced to continue investigation into allegations listed above. LPA met with Administrator Jolene Soi Su during today's visit.
LPA investigated allegation "Staff not following physician's orders for proper irrigation of resident's catheter". LPA conducted a file review for R1. R1 has a Foley catheter which is identified on their LIC602. LPA interviewed R1, in which they stated facility only helps with changing the bag to the night bag to the leg bag for the day and emptying the bag when needed. R1 stated they receive further care from a medical provider outside of the facility. LPA interviewed staff and administrator, in which they state R1 goes to a medical provider when catheter is changed or irrigation is needed. Staff and administrator state they only change the bag, empty the bag, and observe for any changes. Due to the information gathered, LPA finds allegation to be UNFOUNDED.
Continuation on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

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-20210423124730

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: AMERICAN RIVER RESIDENTIAL CARE, LLC	FACILITY NUMBER: 342700792
	VISIT DATE: 05/19/2021

NARRATIVE

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LPA investigated the allegation "Facility does not have non-slip protective devices on resident's bathroom floor". LPA toured the facility and interviewed residents in care. LPA observed the bathroom by the kitchen has a large open shower area and non-slip mats present. Administrator and staff state the residents only use this bathroom for showers. LPA observed the two other bathrooms did not have non-slip mats but do not appear to be in use. LPA interviewed 3 residents, in which they stated they receive showers in the large bathroom by the kitchen. Residents stated there are non-slip mats in the shower. Due to the information gathered LPA finds allegation to be UNFOUNDED.

LPA investigated the allegation "Food service requirements are not being met by facility". LPA toured the kitchen area, and observed the food supply. Facility has two freezers, a refrigerator, and a pantry. LPA observed fresh vegetables and fruits, meats, dairy items, and canned food items. LPA observed that the food items were not expired, and there was a sufficient 2 day perishable and 7 day non-perishable amount of food. LPA interviewed residents in which they stated they are satisfied with the food and received fresh fruits and vegetables with their meals. Due to the information gathered LPA finds the allegation to be UNFOUNDED.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Huusfeldt	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC9099 (FAS) - (06/04)

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