345002868-7-21-2022-25-AS-MSEY-CGSKV9-20220729081353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002868
Report Date: 07/21/2022
Date Signed: 07/21/2022 05:32:02 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
04/12/2022 and conducted by Evaluator Sabrina Calzada

COMPLAINT CONTROL NUMBER: 25-AS-20220412134911

FACILITY NAME:	HAZEL HOME FOR SENIORS		FACILITY NUMBER:	345002868
ADMINISTRATOR:	GRANT, CLEOPATRA		FACILITY TYPE:	740
ADDRESS:	4919 HAZEL AVENUE		TELEPHONE:	(831) 334-1223
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 3	DATE:	07/21/2022
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Diane Evering, caregiver		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

POA not notified of incidents involving resident behavior

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Allegation is resident’s representative was never notified of resident’s behaviors which were the basis of the eviction notice being issued. This allegation was inadvertently not listed on the other report page so is being listed separately.

Licensee stated to LPA on 4/14/22 that resident’s POA was upset that she was not reached out to regarding resident behaviors that were not safe. Eviction letter to resident’s representative states that facility staff have only communicated with resident R1 “on multiple occasions” about her behavior from Feb-April.

Documentation provided by POA notes that on 3/28/22 (5:01 pm) R1 texted her POA that she was reprimanded by staff (S2) for rubbing Mary’s back and that Licensee would send POA a picture of R1 combing R2's hair. POA stated that she never received an emailed picture of R1 combing R2’s hair. Administrator stated she discussed R1's behavior with the POA "very often" since she visited regularly. Licensee stated she also discussed by phone the issues with R1's trying to provide care to R2.

Based on information obtained during the investigation, LPA finds the allegation to be 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 evidence to prove that the alleged violation occurred,

Exit interview. Copy of report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina Calzada	TELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3