342700805-11-16-2023-59-AS-KHOS-CYER6M-20231211114458

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700805
Report Date: 11/16/2023
Date Signed: 11/16/2023 04:56:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/23/2023 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230523134503

FACILITY NAME:	NORTHERNCARE FACILITY		FACILITY NUMBER:	342700805
ADMINISTRATOR:	WOODWARD, ROSE BALURO		FACILITY TYPE:	740
ADDRESS:	5016 WATERBURY WAY		TELEPHONE:	(530) 762-8199
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 6	DATE:	11/16/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Rose Baluro Woodward, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not provide resident with requested documents

Facility does not meet the residents' dietary needs

Staff threatened a resident with eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Rose Baluro Woodward, to deliver findings into the complaint allegations listed above.

During the investigation, the Department conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

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 59-AS-20230523134503

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NORTHERNCARE FACILITY	FACILITY NUMBER: 342700805
	VISIT DATE: 11/16/2023

NARRATIVE

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Relevant party reported to the Department that facility staff did not provide resident with requested documents, facility does not meet the residents' dietary needs, and staff threatened a resident with an eviction.

During the investigation, LPA interviewed Administrator, staff member S1, and residents R1, R2, R3, and R4. Interview with Administrator indicated that there was a recent request for staff records from a resident that could not be released to the resident. Administrator stated that they provided resident records per request of the resident in a timely manner. No other interviews conducted indicated any issues with obtaining records. LPA observed three (3) resident records indicating that a resident had dietary restrictions. Interviews conducted indicated that facility is following residents' dietary restrictions. During investigation, LPA observed a two (2) day perishable and seven (7) day nonperishable food supply at the facility. LPA observed food to be of good quality. No interviews conducted indicated any concerns regarding facility not meeting residents' dietary needs. Administrator stated that one (1) resident had a contract with the facility for one (1) month, in which resident was to move out of the facility after one (1) month. Resident was sent to the hospital, which placed resident in a skilled nursing facility. No other interviews conducted indicated that anyone witnessed or experienced staff threaten them or another resident with an eviction.

Based on interviews conducted 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. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.

SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023

LIC9099 (FAS) - (06/04)

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