342700902-11-8-2023-59-AS-LMUZ-CXN2JR-20231116162647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700902
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:36:17 PM

Unfounded

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
10/26/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20231026084013

FACILITY NAME:	FOLSOM COUNTRYHOUSE		FACILITY NUMBER:	342700902
ADMINISTRATOR:	LETICIA FERMOSO HIGARES		FACILITY TYPE:	740
ADDRESS:	2005 IRON POINT RD		TELEPHONE:	(916) 836-8022
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	60	CENSUS: 42	DATE:	11/08/2023
		UNANNOUNCED	TIME BEGAN:	01:19 PM
MET WITH:	Director of Nursing Brian Pawloski		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff are not acknowledging resident's new POA documents.

INVESTIGATION FINDINGS:

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On 11/8/23, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Director of Nursing Brian Pawloski. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.The results of the investigation are as follows:
R1 was admitted to the facility on 7/27/23. Complaint allegations stated that R1 was placed in the facility against their will. Based on records reviewed and interviews, R1 has a family member as their POA. Based on R1’s medical diagnosis, R1 is not able to make decisions including the ability to change their POA. Staff are acknowledging that another family member wants to be POA, however, the facility cannot address that issue. LIC602 states that R1 is not medically competent to change the POA. Therefore, the allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview was conducted with Director of Nursing and a copy of this report was provided to the facility.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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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