345002868-7-28-2022-25-AS-MSEY-CGSKXW-20220729081813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002868
Report Date: 07/21/2022
Date Signed: 07/28/2022 04:52:21 PM

Unfounded

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
04/11/2022 and conducted by Evaluator Sabrina Calzada

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220411160405

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:	DATE:	07/21/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Diane Evering, caregiver		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff unlawfully evicted a resident

INVESTIGATION FINDINGS:

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

**This report is being amended only to change findings from "Unsubstantiated" to "Unfounded". There are no other changes being made to the report. **

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received by the department on 4/11/2022. LPA met with Diane Evering, caregiver LPA spoke to Administrator and Licensee by phone. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the community. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask.

During the investigation, LPA interviewed Licensee, the Ombudsman, resident (R1), resident (R1)'s family member. LPA reviewed documentation pertaining to resident (R1) including but not limited to, physician's report, pre-appraisal, copy of eviction notices, letter issued to resident for a privacy breech incident, Admission Agreement, and meeting minutes from 4/12/2022. LPA also reviewed resident (R2)'s care plan and physician's report.

The results of the investigation are as follows:

Unfounded

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

Control Number 25-AS-20220411160405

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: HAZEL HOME FOR SENIORS	FACILITY NUMBER: 345002868
	VISIT DATE: 07/21/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: Staff unlawfully evicted a resident.
Allegation states resident (R1) is not following safety instructions, is performing jobs meant for caregivers and is in violation of Section 87224(a) and of the Resident Care Agreement signed on 02-10-2022. Hazel Home has communicated with resident on multiple occasions of their concerns about their behavior. \

LPA was provided on 4/5/22 with an email dated 3/28/22 from Licensee to R1's responsible party/POA serving her with 30 days notice to find another facility for R1, or by 4/27/22, since she is not happy with the facility. The email does not contain all of the required elements per Regulation 87224 so is not a valid eviction notice.

Licensee contacted LPA by phone on 4/5/2022 to discuss issuing an eviction notice to resident (R1). Following the call, LPA emailed Licensee a copy of Regulation 87224, as well as a sample eviction notice. Licensee provided the Department with a copy of an eviction letter, on 4/6/2022, which provides detailed information on (5) separate occasions, between 2/15/2022 and 3/13/2022, where resident was feeding another resident (R2), which posed a choking hazard to R2. Additionally, the letter notes that R1 was massaging R2's shoulders, on 2/22/2022 and on 3/27/2022, placing R1 at an increased fall risk. On 4/7/2022, LPA provided additional guidance to Licensee that an eviction letter needs to contain resources for placement agencies and a sample eviction letter was provided again. LPA received an updated eviction notice on 4/7/22 and replied on 4/8/2022 that the letter appears to contain all required elements per the regulation and so is a lawful eviction notice.

An updated eviction notice was issued by email to resident's representative later on 4/8/22. On 4/12/2022, an in-person meeting was held at the facility with the Licensee, Administrator, resident (R1), R1's representative and the Ombudsman to discuss the eviction notice recently issued as well as other concerns. Copies of meeting notes were provided to the Department on 4/15/22 and note that at the conclusion of the meeting, the facility agreed to withdraw the eviction notice issued on 4/8/22 provided that 1) issues discussed at the meeting were not subsequently repeated and 2) all parties agreed to sign the meeting notes which state, in part, that any allegations previously made against the facility were false. Licensee confirmed on 4/19/22 and on 4/28/22 that the eviction notice issued on 4/8/22 had not been rescinded due to resident's responsible person not being willing to sign the meeting notes. Resident's POA indicated on 4/26/22 that she did not agree with the meeting notes, specifically about false allegations, so she was unwilling to sign and would be moving R1 to another facility.
cont on 9099C(2)..

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20220411160405

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: HAZEL HOME FOR SENIORS	FACILITY NUMBER: 345002868
	VISIT DATE: 07/21/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

90099C(2) ..Regulation 87224 says (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(a) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).

(3)Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement.

POA stated she never received a copy of the Admission Agreement or House Rules, as referenced in the eviction notice on 4/8/22.

Licensee stated that House Rules were included in the Admission Agreement, which was signed by R1's POA upon move-in, on 2/10/2022, and that a resident can be evicted for placing him/herself in a harmful situation or another resident in a harmful situation.

Admission Agreement says under Section 5(a) that a resident can be evicted for the reason of not following the written general policies of the facility. It was not anticipated that a resident would be trying to care for another resident, as in providing care like a caregiver, so it was not specifically written in until the admission policy was updated in May 2022.

Based on information obtained during the investigation, LPA finds the allegation to be UNFOUNDED- A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview. Copy of report provided.

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

LIC9099 (FAS) - (06/04)

Page: 3 of 3