345002868-7-21-2022-25-AS-MSEY-CGSKV8-20220729081353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002868
Report Date: 07/21/2022
Date Signed: 07/21/2022 05:18:37 PM

Substantiated

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

PUBLIC

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:	03:00 PM
MET WITH:	Diane Evering, caregiver		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Not enough staff to supervise residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received by the department on 4/12/2022. LPA met with Diane Evering, caregiver LPA spoke to Administrator, Cleo Grant, andf Licensee, Farah Chaudhary, 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. LPA observed resident (R5) return from the hospital after being sent out earlier today for a fall. LIC624 to be submitted.

During the investigation, LPA interviewed Licensee, the Administrator, the Ombudsman, resident (R1), resident (R1)'s representative (POA) and another resident. 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, signed Admission Agreement, and meeting minutes from 4/12/2022. LPA also reviewed residents' (R2 and R3) care plans and physician's reports.

The results of the investigation are as follows:

Substantiated

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 6

Control Number 25-AS-20220412134911

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

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Allegation: Not enough staff to supervise residents.
Allegation refers too the incident on March 3, 2022 when resident (R3) eloped from the facility and there were not enough staff to monitor the residents.

Interviews conducted in April 2022 with (2) residents confirmed that residents (R1, R2 and R4) were left alone at the facility on 3/3/22, for approximately one hour, while the only staff (S1) on duty, went to find resident (R3) after she left the facility unattended. Text message sent from one resident to a family member notes that on 3/3/22 at 2:20 pm, she and another resident were sitting outside on the porch waiting for S1 to return with resident, R3.

Based on information obtained during the investigation, LPA finds the allegation to be SUBSTANTIATED- a finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Because this incident occurred on 3/3/22, prior to the current license being issued on 3/9/22, this citation and any related citations and civil penalties are being issued on the prior license, #342700078.

Exit interview with caregiver, Diane, which was authorized by Administrator Cleo.. 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: 6 of 6

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

PUBLIC

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:	DATE:	07/21/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Diane Evering, caregiver		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Not enough proof given for eviction
Staff talking about residents to people who are not responsible parties.
Staff having residents supervise other residents.
POA did not receive a copy of the admission agreement.
POA not notified of incidents involving resident behavior

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received by the department on 4/12/2022. LPA met with Diane Evering, caregiver LPA spoke to Administrator and Licensee by phone.

During the investigation, LPA interviewed Licensee, the Administrator, the Ombudsman, resident (R1), resident (R1)'s family member and another resident. 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 residents' (R2 and R3) care plans and physician's reports.

The results of the investigation are as follows:

cont on 9099A(C1)..

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: 2 of 6

Control Number 25-AS-20220412134911

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

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Allegation: Not enough proof given for eviction.
Allegation is facility did not provide enough proof to justify the eviction.

Health and Safety Code §1569.683 Eviction notices; reasons for eviction contents; services (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons.

Eviction letters issued on 4/6/22 and on 4/8/22 both provide specific details, including the day and time for the (5) different times when R1 was assisting with feeding R2 and both times when R1 was giving R2 a massage, which would allow the incidents to be viewed on the video camera in the common areas. POA provided documentation that on 3/28/22 Licensee advised resident R1 that she would send representative a picture of R1 combing resident Mary’s hair. POA stated she never received an emailed picture. Licensee stated that these incidences are documented by video in the common area when they occurred. Administrator stated that she showed R1's POA a picture of R1 feeding R2 and combing her hair and massing her. Administrator also stated that she showed a picture to POA of her taking a picture of R5's journal.

Based on documentation review and interviews conducted, LPA finds this 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 the evidence to prove that the alleged violation occurred.

Allegation: Staff talking about residents to people who are not responsible parties.
Allegation is Licensee talks about other residents’ conditions to people who are not responsible parties

Interview with one resident revealed that Licensee hasn't talked to her about other residents' information. Two other residents were not able to be interviewed due to a diagnosis of Dementia,. LPA reviewed the eviction letter issued to R1 which mentions that another resident (R2) “is unable to state on her own cognitive will when to stop eating”. Based on interviews conducted throughout the investigation, residents and staff were POA was aware that R2 had cognitive challenges and needed assistance with feeding.

Based on documentation review and interviews conducted, LPA finds this 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 the evidence to prove that the alleged violation occurred.
cont on 9099A(C2)..

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: 4 of 6

Control Number 25-AS-20220412134911

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

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Allegation: Staff having residents supervise other residents.

Allegation is when resident’s responsible person arrived for a visit, she found R2 sleeping in the recliner in R1's room.

LPA reviewed documentation provided by R1's POA, dated 3/8/22, which states that when R1's POA arrived to visit R1, as she does nightly, resident (R2) was asleep in R1’s recliner. When asked about it, R1 stated “they dropped her off for me to babysit”. The documented notes further states “as soon as (S1) realized I was there and R2 was still in my mom’s room, she rushed R2 to bed”.

Additional documentation provided by R1's POA, specifically a text message dated 3/25/22, notes that staff (S1) asked resident (R1) to watch the other 3 residents (R2, R3 and R5) who were also sitting at the table while she went to assist another resident (R4) who was having an asthma attack. The notes further document that S1 screamed at R1, asking her to not get out of her chair and assist her in watching the other residents.

A staffing schedule was provided for the third/fourth week of April 2022, as requested, and shows that 1 caregiver is scheduled to work from 7 am- 7 pm and a second caregiver is scheduled to work from 7 pm- 7 am daily. Licensee stated on 4/14/2022 that she has one staff on duty with four residents. In March 2022, there were 5 residents in care and 1 staff on duty during these noted incidents on 3/8/22 and 3/25/22. Administrator stated that when there were (5) residents in March 2022, a second, live-in staff (S1) would assist when needed.

S1 stated to LPA on 4/14/22 that residents "all eat lunch together", stating "I don't ask a resident to watch another resident". They are all together for lunch and dinner". Administrator stated she is not aware of this happening and never observed any staff to ask a resident(s) to watch another resident(s).

Based on information obtained, 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 the evidence to prove that the alleged violation occurred.

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 6

Control Number 25-AS-20220412134911

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

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Allegation: POA did not receive a copy of the admission agreement.
Allegation states that resident and responsible person never received a copy of the Admission Agreement.

POA stated on 4/26/22 that she never received a copy of the Admissions agreement upon move in February 2022. Ombudsman stated that at the conclusion of the meeting he attended on 4/12/22 with the Licensee, Administrator, resident (R1) and resident’s representative, he requested that Licensee make a copy of the Admission Agreement for resident since she hadn’t received one upon move-in, in February 2022.
Administrator and Licensee both indicated that R1 received a copy of the admission agreement upon move-in and received a second copy on 4/12/22 following the meeting held with the Ombudsman.

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 to Administrator.

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)

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