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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700872
Report Date: 09/18/2024
Date Signed: 09/18/2024 03:58:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
03/06/2024 and conducted by Evaluator Kimberly Viarella
COMPLAINT CONTROL NUMBER: 27-AS-20240306161850
FACILITY NAME:MASON'S HOME, LLCFACILITY NUMBER:
342700872
ADMINISTRATOR:WONG, SALLYFACILITY TYPE:
735
ADDRESS:4521 EXCELSIOR RDTELEPHONE:
(916) 402-3830
CITY:MATHERSTATE: CAZIP CODE:
95655
CAPACITY:4CENSUS: 4DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Sally WongTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident was denied medical treatment for a wound sustained while in care.
INVESTIGATION FINDINGS:
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On 09/18/24, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of the investigation into the above complaint. LPA identified herself upon arrival, stated the purpose of the visit and asked to meet with the Licensee/Desingated Facility Administrator (DFA). Staff called the DFA and she arrived shortly after. LPA met with Sally Wong and a brief interview followed.

LPA began the visit with a brief walkthrough of the facility. Two residenst were in the front room listening to music and interracting with staff. Two residents were at Day Program. LPA toured all the resident bedrooms, bathrooms as well as the laundry room and garage and observed that the rooms contained all of the required items and were neat and organized.

LPA condducted interviews and a record review during visits on 3/13/24 and 9/18/24. 4 out of 4 people interviewed stated that R1 had some kind of scratch or bite on their arm and had requested to go to the doctor's/urgent care. This LPA learned through a review of records, that on 3/4/24, when R1 returned to the
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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 27-AS-20240306161850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MASON'S HOME, LLC
FACILITY NUMBER: 342700872
VISIT DATE: 09/18/2024
NARRATIVE
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home, R1 told staff that they wanted to see the doctor about their arm. On 3/5 in the care notes, staff wrote that R1 told staff they were going to call an ambulance. Staff told R1 "just need to clean the wound and put medicine on it but she ignore staff."

This LPA learned through interviews that staff did contact a doctor and that an appointment was set up approximately a week later, however R1 was requesting immediate medical attention and had a right to see a doctor upon request. R1 was observed by an outside agency to have a fluid filled blister, the size of which was between a nickel and a dime, on R1's shoulder. R1 was complaining of pain and wanted to be taken to a doctor for evaluation. No one at the facility had the authority to make the decision to deny R1 medical attention.

The standard for the preponderance of evidence has been met, the allegation, "Resident was denied medical treatment for a wound sustained while in care," has been substantiated.

According to the California Code of Regulations, this deficiency is cited on the LIC 9099 D page. A copy of this report along with APPEAL Rights were provided and an exit interview was conducted.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20240306161850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: MASON'S HOME, LLC
FACILITY NUMBER: 342700872
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2024
Section Cited
CCR
85075
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(CCR 85075 (b) The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.

This requirement was not met as evidenced by:
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Administrator will contact an outside agency (possibky ombudsman) to conduct a staff training on personal rights with an emphasis on a right to medical care. This training will be completed by 10/18/24 and the name of the facilitator and a signature sheet of participants will be submitted to CCL at
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The facility did not send the client out for medical attention when the resident requested a medical evaluation for a wound on their shoulder. This posed a potential threat to the health, safety and personal rights of the resident in care.
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kimberly.viarella@dss.ca.gov by the close of business on 10/18/24
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3