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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345002938
Report Date: 09/12/2023
Date Signed: 09/12/2023 08:03:33 PM

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
02/16/2023 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 25-AS-20230216182434
FACILITY NAME:COZY HOME CAREFACILITY NUMBER:
345002938
ADMINISTRATOR:BRIONES, AIDA R.FACILITY TYPE:
740
ADDRESS:5643 CLARK AVE.TELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Khanika MoodieTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff illegally evicted resident
INVESTIGATION FINDINGS:
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On 9/12/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding for the allegation listed above. LPA met with caregiver, Khanika Moodie, and explained the purpose of the visit. Caregiver contacted Administrator who stated she is 40 minutes away and visit can be conducted with caregiver.

During the investigation of this complaint, the Department conducted interviews and record review for the allegation cited above.

Results are as follow, please continue report on LIC 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
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 5
Control Number 25-AS-20230216182434
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: COZY HOME CARE
FACILITY NUMBER: 345002938
VISIT DATE: 09/12/2023
NARRATIVE
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Allegation: Staff illegally evicted resident

The Department conducted records review and interviews to investigate this allegation. Interview conducted on 2/24/2023 with Administrator indicated that R1 has been residing at the facility for approximately three days prior to hospitalization. Administrator stated that during R1’s duration at the facility, R1 refused to eat and/or be changed by caregivers. R1 was sent to Mercy San Juan Emergency Room for evaluation. Administrator reported to hospital social worker that due to concerns of R1’s health and safety, R1 cannot return to the facility until she is conserved. Administrator stated a 30-day eviction notice was not provided to R1.

Based on the allegation, staff illegally evicted resident, the allegation is SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency cited on LIC9099D.

Exit interview conducted, a copy of the report and appeal right was provided.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
02/16/2023 and conducted by Evaluator Cassie Yang
COMPLAINT CONTROL NUMBER: 25-AS-20230216182434

FACILITY NAME:COZY HOME CAREFACILITY NUMBER:
345002938
ADMINISTRATOR:BRIONES, AIDA R.FACILITY TYPE:
740
ADDRESS:5643 CLARK AVE.TELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
09/12/2023
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Khanika MoodieTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not ensure resident was adequately fed
Staff financially abused resident
INVESTIGATION FINDINGS:
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On 9/12/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to deliver the finding for the allegation listed above. LPA met with caregiver, Khanika Moodie, and explained the purpose of the visit. Caregiver contacted Administrator who stated she is 40 minutes away and visit can be conducted with caregiver.

During the investigation of this complaint, the Department conducted interviews and record review for the allegations cited above.

Results are as follow, please continue report on LIC 9099-C...
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20230216182434
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: COZY HOME CARE
FACILITY NUMBER: 345002938
VISIT DATE: 09/12/2023
NARRATIVE
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Allegation: Staff did not ensure resident was adequately fed.

The Department conducted records review and interviews to investigate this allegation. Record review indicated that on date of admission R1 was given fruits to eat. It further indicated that R1 was “offered fruits and she ate berries, strawberries, and slices of bananas.” Additionally, record review indicated the following day after R1’s admission, “she only ate a few fruits for breakfast and did not eat lunch. She drank a sip of ensure., Five grapes for dinner.” Interviews conducted indicated that staff continuously offered R1 food, but R1 refused.


Allegation: Staff financially abused resident.

The Department conducted interviews to investigate this allegation. Interview conducted with S1 indicated that S1 does not have access to R1’s account and/or have S1 taken R1 to the bank to withdrawal money. Interview conducted with S2 indicated since R1’s admission R1 has not vacated the premises until hospitalization. S2 stated staff did not take R1 to the bank. Interview conducted with Licensee indicated Licensee met with R1 and R1’s transporter at the bank, but it was to help R1’s transporter navigate to the facility as money was not withdrawn in her presence.

During this investigation, LPA conducted records review and extensive interviews regarding the cited allegations above. LPA found the facility to be compliance with Title 22. Based on interviews conducted, the preponderance of evidence standards have not been met. 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 conducted, a copy of the report and appeal right was provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20230216182434
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: COZY HOME CARE
FACILITY NUMBER: 345002938
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
87224(a)(4)
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87224 Eviction Procedures
(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by:
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Licensee is to submit a statement of compliance with Eviction Procedures to LPA Yang by close of business Friday September 29, 2023.
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Based on records review and interviews, Licensee did not comply with the section cited above, as Licensee did not provide R1 a 30-day eviction notice as Administrator reported R1 cannot return to the facility until R1 has a conservator, which poses a potential health and safety risk for residents 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5