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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700902
Report Date: 12/11/2023
Date Signed: 12/11/2023 11:22:42 AM

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
11/03/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20231103110803
FACILITY NAME:FOLSOM COUNTRYHOUSEFACILITY NUMBER:
342700902
ADMINISTRATOR:LETICIA FERMOSO HIGARESFACILITY TYPE:
740
ADDRESS:2005 IRON POINT RDTELEPHONE:
(916) 836-8022
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:60CENSUS: 46DATE:
12/11/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Danielle PeckTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not respond to residents call pendant in a timely manner.
Staff mismanaged residents medication.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/11/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with administrator, Danielle Peck.

During the investigation, the Department conducted interviews 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:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
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 4
Control Number 59-AS-20231103110803
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: FOLSOM COUNTRYHOUSE
FACILITY NUMBER: 342700902
VISIT DATE: 12/11/2023
NARRATIVE
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9
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Allegation- Staff does not respond to residents call pendant in a timely manner. 
 
The department conducted staff and residents' interviews, reviewed records to investigate the allegation. During interviews, staff stated that staff respond to resident call buttons in a timely manner, however, sometimes there is a delay in response due to staff assisting other resident’s needs. During facility observation on 11/8/23 and 11/20/23 and call log review, the department did not observe any long/extended wait times from staff to respond to resident's call button, therefore this allegation is found to be UNSUBSTANTIATED. A finding that the complaint 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. 
 
Allegation- Staff mismanaged residents medication. 

Based on documents obtained and statements received, the department determined that there was insufficient evidence that staff did not properly maintain medication for residents in care. Documents reviewed show that all current medications were administered and logged correctly and were given to residents per their doctor's orders from 11/1/23-11/17/23. Based upon the information obtained during investigation, the above allegation is unsubstantiated. A finding that the complaint 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 and a copy of this report was provided to the facility.







SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
11/03/2023 and conducted by Evaluator Talwinder Bains
COMPLAINT CONTROL NUMBER: 59-AS-20231103110803

FACILITY NAME:FOLSOM COUNTRYHOUSEFACILITY NUMBER:
342700902
ADMINISTRATOR:LETICIA FERMOSO HIGARESFACILITY TYPE:
740
ADDRESS:2005 IRON POINT RDTELEPHONE:
(916) 836-8022
CITY:FOLSOMSTATE: CAZIP CODE:
95630
CAPACITY:60CENSUS: 46DATE:
12/11/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Danielle PeckTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff forced resident to shower.
Facility does not have sufficient staff to provide care to residents.
Staff did not properly supervise resident resulting in a fall.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/11/23, Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator, Danielle Peck.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.


The results of the investigation are as follows:



**Report continued on 9099-C**
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20231103110803
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: FOLSOM COUNTRYHOUSE
FACILITY NUMBER: 342700902
VISIT DATE: 12/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation- Staff forced resident to shower. 

Based on records reviewed and interviews conducted it was determined by the department that (per facility policy) if residents refuse to shower, staff will redirect, come back a few minutes later, or change face. If all those steps are taken, and residents still refuse to shower, staff then document refusal in the residents’ charts. From records reviewed, the department observed that staff were documenting all shower related documentation per facility policy and were not forcing any residents to take showers if they refused. 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. 
 
Allegation- Facility does not have sufficient staff to provide care to residents. 

LPA has reviewed facility schedules which shows shifts are covered by multiple staff. There is no evidence to support the allegation that the facility does not have sufficient staff to provide care to residents. From records review, LPA learned that there are at least 2 direct care staff available on each floor during each shift for every day.  Residents' interviews indicated that their needs are met, and the department finds no evidence that the current staff level is insufficient. 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.   
 
Allegation- Staff did not properly supervise resident resulting in a fall.
 
Based on records reviewed and interviews conducted, the department determined that R1 did not have any falls in the months of September, October, and November (2023). 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 and copy of this report has been provided.



SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4