342701238-12-17-2024-27-AS-KHOS-DCPPY7-20250107104329

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701238
Report Date: 12/17/2024
Date Signed: 12/17/2024 01:10:34 PM

Unsubstantiated

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
10/07/2024 and conducted by Evaluator Christina Valerio

COMPLAINT CONTROL NUMBER: 27-AS-20241007152832

FACILITY NAME:	STAYPOINT RESIDENTIAL		FACILITY NUMBER:	342701238
ADMINISTRATOR:	OGENAH, OGIATOR MICHEAL		FACILITY TYPE:	735
ADDRESS:	167 DANNY DR		TELEPHONE:	(408) 373-7750
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY:	6	CENSUS: 0	DATE:	12/17/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Edirin Osah		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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Due to lack of supervision, resident assaulted another resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio contacted designated staff/manager Edirin Osah via cell phone. LPA learned the last resident in care moved out on 12/13/2024. LPA was later met by Edirin Osah at the facility.

The investigation consisted of interview with staff, review of facility program design, records review of resident files, records review of staff schedules, and records review of submitted unusual incident reports for Resident 1 (R1) and Resident 2 (R2).

Per the Program Design (offered program services), the facility is licensed is serve six (6) adults with an age range of 18-59, and approved to have 2 of the 6 residents considered nonambulatory.

Continues on LIC 9099 - C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

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-20241007152832

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: STAYPOINT RESIDENTIAL	FACILITY NUMBER: 342701238
	VISIT DATE: 12/17/2024

NARRATIVE

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Continued from LIC 9099

The facility provides Lodging, Food services, Laundry Service, Cleaning of client room, arrange and provide transportation to appointments, a planned activity program, "continuous observation, care and supervision, as required", assistance with bathing and personal needs, as required, assistance with meeting necessary medical and dental needs, assistance with taking prescribed medications, and optional services for a fee.

Per review of the facility schedule, the licensee scheduled one direct care staff per shift. It was observed that anytime there was more than one (1) staff member is when an administrator is on the schedule.

Per review of resident records for R1 and R2. According to the LIC 602 Physician Report, both residents are able to care for all needs, able to leave the facility unassisted, and does not need constant medical supervision. According to R1's appraisal, R1 was not on a 1:1 staffing ratio. According to R2's appraisal, R2 was not on a 1:1 staffing ratio.

Per review of an unusual incident report submitted by the facility, R2 went into R1's bedroom and made physical contact with R1's head. According to R1, the assault was unprovoked. R1 reported the incident to the staff member on shift, which then contacted Galt Police Department, the Administrator, and both resident's case manager. During the incident, staff on shift was completing R1's laundry. Based on staff interviews, R2 has not assaulted a resident in care prior to the incident on 10/05/2024.

Although R2 assaulted R1, records review and staff interviews show that there were staff on shift and there was no indication of neglect or lack of supervision. Staff on shift were completing other household duties for residents in care. Staff was also immediately present after the incident occurred. The facility is required to have one staff on shift, which the requirement was met.

Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, no deficiencies are being cited. An exit interview was held and a copy of report was left.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024

LIC9099 (FAS) - (06/04)

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