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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002915
Report Date: 02/22/2024
Date Signed: 02/22/2024 10:10:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
11/20/2023 and conducted by Evaluator Cheyenne Ratajczak
COMPLAINT CONTROL NUMBER: 59-AS-20231120155914
FACILITY NAME:RCCA COMMUNITY ACCESS PROGRAMFACILITY NUMBER:
345002915
ADMINISTRATOR:ELSTON, SHARRAEFACILITY TYPE:
775
ADDRESS:4980 WATT AVENUE SUITE CTELEPHONE:
(530) 933-1590
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:43CENSUS: 21DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:43 AM
MET WITH:Program Manager - Ashely ThomasTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Licensee did not complete a written needs and services plan for client.
Staff did not ensure client was adequately secured in a wheelchair.


INVESTIGATION FINDINGS:
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On 02/22/24, Licensing Program Analyst (LPA) Cheyenne Ratajczak arrived at the facility unannounced to deliver final findings Community Care Licensing (CCL) received on 11/20/23. LPAs met with Program Manager (PM), Ashley Thomas, and explained the purpose of the visit.

During the course of this investigation, the Department conducted interviews and obtained pertinent documents relevant to the complaint investigation.

Please continue to LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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 59-AS-20231120155914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: RCCA COMMUNITY ACCESS PROGRAM
FACILITY NUMBER: 345002915
VISIT DATE: 02/22/2024
NARRATIVE
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Allegation: Licensee did not complete a written needs and services plan for client.- Substantiated

The Department reviewed records and conducted interviews to investigate the allegation that the licensee did not complete a written needs and service plan for client.

During the course of the investigation, LPA reviewed four (4) client files. A review of three (3) out of the four (4) client’s needs and service plans were outdated. Client #1 (C1), Client #3 (C3) and Client #4 (C4) needs and service plans were observed to be all over a year old.

Based on LPAs observations and interviews which were conducted and record reviews, the facility did not ensure that all clients’ needs and service plans are updated and current. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D

Allegation: Staff did not ensure client was adequately secured in a wheelchair.- Substantiated

Interviews indicated that on 10/02/2023 when C1 arrived home from the program, it was observed that C1’s 5- point harness seat belt on C1’s wheelchair was looped under C1’s backpack and not secured or fastened. Based on interview conducted, the program safety protocol includes a two-person check. When a client is leaving the program, the program staff as well as transportation staff are to double check when securing client’s chairs into place. When the program was notified of the incident on 10/02/2023, S1 acknowledged the error and stated the situation would be addressed. Records reviewed indicated that C1’s medical needs include C1 requiring a 5- point harness seatbelt in their wheelchair to prevent C1 from slipping and/ or falling out.

Based on LPAs observations and interviews which were conducted and record reviews, the facility did not ensure that C1 was properly secured in their wheelchair before transportation. Therefore, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D

Exit interview conducted and a copy of the report and appeal rights were left at the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20231120155914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: RCCA COMMUNITY ACCESS PROGRAM
FACILITY NUMBER: 345002915
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2024
Section Cited
CCR
82068.3(a)
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Modifications to Needs and ServicesPlan (a)The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary, but at least annually, to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental, psychological, and/or social functioning.
This requirement is not met as evidenced by
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Facility is to submit to LPA Ratajczak a statement of understanding the importance of updating needs and service plans annually. Additionally, Licensee is to audit all files to ensure that clients have an updated needs and service.
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Based on observation, the licensee did not comply with the section cited above in 3 out of 4 clients, do not have current and updated needs and service plans which poses a potential health, safety and personal rights risk to persons in care.
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Type B
03/07/2024
Section Cited
CCR
82072(a)(2)
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82072 Personal Rights(a)Each client shall have personal rights which include, but are not limited to, the following:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by
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Licensee is to come up with and submit to the department a procedure plan regarding wheelchair safety and conduct a training with all staff on the procedure.
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Based on interview, the licensee did not comply with the section cited above in 1 out of 1 client, was not properly secured in their wheelchair which poses a potential health, safety and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Cheyenne Ratajczak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3