342700902-3-8-2023-25-AS-LMUZ-CPVKYH-20230313081910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700902
Report Date: 03/08/2023
Date Signed: 03/08/2023 01:18:37 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/18/2022 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 25-AS-20220718160858

FACILITY NAME:	FOLSOM COUNTRYHOUSE		FACILITY NUMBER:	342700902
ADMINISTRATOR:	MUSTAFA ALI-MAHGOUB		FACILITY TYPE:	740
ADDRESS:	2005 IRON POINT RD		TELEPHONE:	(916) 836-8022
CITY:	FOLSOM	STATE: CA	ZIP CODE:	95630
CAPACITY:	60	CENSUS: 37	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator Thach N Duong		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Resident’s Representative’s request for assistance for resident in care were not responded to in a timely manner.
Facility does not have sufficient staff to meet the needs of the residents in care.

INVESTIGATION FINDINGS:

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On 03/08/2023, Licensing Program Analysts (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Thach Duong. Prior to visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: surgical mask.

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**

Substantiated

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: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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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Control Number 25-AS-20220718160858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: FOLSOM COUNTRYHOUSE	FACILITY NUMBER: 342700902
	VISIT DATE: 03/08/2023

NARRATIVE

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Resident’s Representative’s request for assistance for resident in care were not responded to in a timely manner.
An investigation has been conducted regarding the allegation above. It was noted during interviews that Witness 1 (W1) was visiting R1 at the facility and noticed feces on the toilet seat. W1 asked staff members to clean R1’s bathroom however, staff did not clean the bathroom until a couple days later therefore the allegation is substantiated. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D.

Facility does not have sufficient staff to meet the needs of the residents in care.
An investigation has been conducted in the allegation above. Review of documents and staff schedules indicate there are enough staff in numbers to meet the needs of the residents in care however, staff stated they were not properly trained to answer immediate requests of residents. Although the facility has sufficient staff in numbers, the facility staff are not sufficient and competent to perform necessary duties due to a lack of training therefore the allegation is substantiated. Based on the departments observations, interviews conducted, and record(s) reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is/are found to be SUBSTANTIATED. California Code of regulations are being cited on the attached LIC9099D.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents. Appeal rights were provided.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20220718160858

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: FOLSOM COUNTRYHOUSE	FACILITY NUMBER: 342700902
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/17/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The administrator will conduct periodic inspections of the memory care unit to check for clean bathrooms. The administrator will meet with staff and provide instruction on reporting unclean toilets to management. A copy of this training shall be submitted to licensing upon completion by 3/17/2023.
	8 9 10 11 12 13 14	LPA noticed multiple bathrooms unclean in resident’s rooms, which poses a potential health, safety, and personal rights risk to the residents in care.	8 9 10 11 12 13 14
Type B 03/17/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator to provide CCL with a plan by 3/17/2023 to ensure personnel will be sufficient in numbers AND competent.
	8 9 10 11 12 13 14	Based upon observation and interview the Licensee failed to ensure staff are competent to provide services necessary to meet resident needs. This poses a potential health, safety and/or personal rights risk to residents in care.	8 9 10 11 12 13 14

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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