342700902-11-8-2023-59-AS-LMUZ-CXN2JD-20231116162611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700902
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:37:30 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
10/12/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20231012162435

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:	01:05 PM
MET WITH:	Director of Nursing Brian Pawloski		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff slapped resident
Staff intimidated resident
Staff did not report physical abuse of resident
Staff do not treat clients with dignity and respect

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:

**Report continued on 9099-C**

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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Control Number 59-AS-20231012162435

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: 11/08/2023

NARRATIVE

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Staff slapped resident
Staff intimidated resident
Staff did not report physical abuse of resident
Staff do not treat clients with dignity and respect
Based on records reviewed and interviews, it was determined that R1 was not slapped or abused by any staff at the facility. Based on interviews conducted, no marks were noticed on R1 after the incident was alleged. Records review indicated that R1 has a history of hallucinations and dementia and regularly says that someone is hitting someone. Law enforcement was involved, did their own investigation, and they did not substantiate the allegations above. Regarding staff not treating residents with dignity and respect, all residents interviewed stated that staff are very respectful to them and other residents, and no one had issues with staff. Staff and resident interviews did not indicate any physical abuse happening at the facility. Based on all this information, all above allegations are 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.

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

LIC9099 (FAS) - (06/04)

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