342701191-12-28-2023-27-AS-KHOS-CZRRD5-20240123115523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701191
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:09:03 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
11/30/2023 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20231130162018

FACILITY NAME:	CA CARING HANDS		FACILITY NUMBER:	342701191
ADMINISTRATOR:	KHAN, SHAHBAZ		FACILITY TYPE:	740
ADDRESS:	8797 TWINBERRY WAY		TELEPHONE:	(916) 667-3248
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	12/28/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Shahbaz Khan		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Facility staff left resident laying in soiled bedding.
Facility staff did not meet resident's hygiene needs.
Facility staff did not rotate a resident with pressure injuries.
Facility staff did not follow resident's hospice care plans.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conclude a complaint investigation on 12/28/23 at 9am. LPA met with Administrator Shahbaz Khan and stated the purpose of the visit. On 12/1/23, LPA obtained copies of resident #1 (R1) complete file which included hospice records and interviewed staff #1 (S1-S2), Applied Palliative and Hospice Services Inc, representative, complainant and responsible party. LPA reviewed the documents obtained and conducted additional interviews today of staff # 3 and Administrator. LPA obtained copies of the visitation log for November 2023.

The investigation revealed that R1 was receiving hospice care services during the time of residing in the facility. A review of the Applied Palliative and Hospice Services, Inc. Care Notes dates from 1/30/23 to 11/29/23 revealed that R1 was receiving wound care from the Hospice Agency beginning 4/26/23. Based on interviews R1 had skin tears, and rashes upon admission that cleared. This was from having fragile skin integrity due to progressive Parkinsons and Vascular Disease diagnosis. See 9099C for Continuation...

Unfounded

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

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 27-AS-20231130162018

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CA CARING HANDS	FACILITY NUMBER: 342701191
	VISIT DATE: 12/28/2023

NARRATIVE

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9099 Continued...

All interviews of staff, administrator, Hospice representative concur that R1 was not left laying in soiled bedding.

All concur that R1s hygiene was properly taken care of throughout every day.

All concur that the hospice care plan was being followed which entailed rotating and turning resident.

LPA observed through a review of the hospice documentation that the hospice agency met with R1s family on several occasions regarding issues and concerns explaining the progression of R1s diagnosis and care needs. During interviews licensed medical professionals did not confirm the facility staff were at fault.

Based on the review of documentation and interviews the preponderance of evidence has not been met. The allegation is deemed UNFOUNDED.

"The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint."

Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023

LIC9099 (FAS) - (06/04)

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