342700856-10-7-2022-25-AS-KHOS-CK4NWK-20221011104940

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700856
Report Date: 10/07/2022
Date Signed: 10/07/2022 04:58:26 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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
10/03/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20221003122644

FACILITY NAME:	A HEARTY CARE HOME IV		FACILITY NUMBER:	342700856
ADMINISTRATOR:	ARGANA, FERDINAND		FACILITY TYPE:	740
ADDRESS:	8734 SOTHEBY CT.		TELEPHONE:	(916) 267-5275
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 3	DATE:	10/07/2022
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Maria Clardy, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff restrained resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Maria Clardy, to open a complaint investigation into the allegation listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises.

During today’s visit, LPA conducted interviews and toured the facility.

The results of the investigation are as follows:

Allegation: Staff restrained resident

** Report continued on 9099-C **

Substantiated

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: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

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-20221003122644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A HEARTY CARE HOME IV	FACILITY NUMBER: 342700856
	VISIT DATE: 10/07/2022

NARRATIVE

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On 10/3/2022, the Department received an email from Administrator indicating that "a resident on hospice" (R1) became "very agitated" and staff "gave [them] an activity to entertain" themselves. Administrator indicated that activity (fidget blanket) was given to them via Sutter Hospice. Email from Administrator stated that "the belt was tied up behind [R1's] chair...instead of [R1's] waist." Email included a picture of the fidget blanket, which has two straps to wrap around the waist of an individual.

During inspection conducted on 10/7/2022, LPA observed fidget blanket and chair R1 was sitting in when strapped with the fidget blanket. LPA interviewed Administrator, who stated that, on 10/1/2022, fidget blanket was strapped around R1 while they were sitting in their chair and staff member did not notice that blanket was wrapped around the chair instead of R1's waist. Administrator stated that staff were with R1 during the time when fidget blanket was wrapped around R1's chair. Once staff observed that fidget blanket was strapped around R1's chair, fidget blanket was removed from R1.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Administrator's signature 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: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20221003122644

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A HEARTY CARE HOME IV	FACILITY NUMBER: 342700856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/07/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/22/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will complete a statement of understanding regarding regulation 87468.1. Facility will submit statement of understanding to LPA by POC due date of 10/22/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure that R1 was not restrained in their chair by a fidget blanket, which poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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