342700927-9-15-2022-25-AS-KHOS-CJGPLC-20220921112432

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700927
Report Date: 09/15/2022
Date Signed: 09/15/2022 03:25:48 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2022 and conducted by Evaluator Kevin Mknelly

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220603085534

FACILITY NAME:	AUGUSTUS ELDER CARE HOME, LLC		FACILITY NUMBER:	342700927
ADMINISTRATOR:	ARAGON, LEILANI		FACILITY TYPE:	740
ADDRESS:	5105 SCHUYLER DR		TELEPHONE:	(925) 922-4561
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	09/15/2022
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Audrey Whittaker Brisse		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility did not meet resident's hygiene needs.
Facility did not ensure that resident had clean clothing.
Facility did not provide resident mobility outside of bed.
Facility did not allow resident to have visitors outside of designated hours.
Facility did not manage resident's medications properly.

INVESTIGATION FINDINGS:

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On 9/15/22, Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met house manager. Prior to initiating the complaint 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 symptom. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical. Additionally, LPA was screened with temperature at the facility.

LPA conducted records review and extensive interviews. Including three interviews today.
LPA is unable to find and or meet the preponderance, per policy.

Statements from caregivers contradicted statements from others known by R1. R1 is unable, due to disability, to report historical information. Roommate of R1 also was unable to report historical

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

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-20220603085534

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: AUGUSTUS ELDER CARE HOME, LLC	FACILITY NUMBER: 342700927
	VISIT DATE: 09/15/2022

NARRATIVE

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information. Neither current nor facility caregivers were able to provide contact information for the home health nurse who saw R1 at the facility. R1 had discharged from the facility before the complaint was filed. LPAs were unable to witness if allegations were accurate while resident was in care.

As a result of this investigation, LPA finds allegation to be (US)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 with administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022

LIC9099 (FAS) - (06/04)

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