345002979-12-14-2023-59-AS-KHOS-CZ7SJ2-20240105125422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345002979
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:28:49 PM

Unfounded

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
06/27/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230627082814

FACILITY NAME:	ONLY LOVE ELDERLY CARE HOME		FACILITY NUMBER:	345002979
ADMINISTRATOR:	LIM, KAREN		FACILITY TYPE:	740
ADDRESS:	4901 MELVIN DR		TELEPHONE:	(808) 228-0588
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS:	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Administrator, Karen Lim		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff leaves resident in diaper for an extended period of time.
Staff does not properly change resident's colostomy bag.
Staff does not have proper training.
Staff is unable to communicate with resident due to language barrier.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver complaint findings for the allegation cited above. LPA met with Administrator, Karen Lim, and explained the purpose of the visit.

During the course of investigation, LPA conducted file review, staff interviews and resident interviews.

The results of the investigation are as follow.

Please continue on LIC 9099-C...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: 916-201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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 4

Control Number 59-AS-20230627082814

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: ONLY LOVE ELDERLY CARE HOME	FACILITY NUMBER: 345002979
	VISIT DATE: 12/14/2023

NARRATIVE

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LIC 9099-C...

Allegation: Staff leaves resident in diaper for an extended period of time.
Based on interviews conducted, it revealed staff are assisting within continence care at least three times a day. Interviews revealed staff changes residents around meal time. Interviews further revealed that if a resident is known to have frequent incontinence, additional changes will be conducted. During interviews conducted with R1, it revealed R1 does not know if she is being in her diaper for extended period. Interview with R2 revealed, R2 has no complaints regarding care in the facility. Interview with R3's family member, it revealed there are no complaints regarding incontinence care.

Allegation: Staff does not properly change resident's colostomy bag.
Based on interview conducted with Administrator revealed facility staff are not trained to change R1's colostomy bag. Interview revealed R1 has home health visits twice a week to change the colostomy bag. Staff are in charge of cleaning around the wound if there is leakage. Additionally, interview revealed facility staff assist with draining the bag daily. Interview conducted with S1 revealed S1 is not trained to change the bag but helps R1 if colostomy bag is pulled. S1 stated home health gets contacted for the assistance.

Allegation: Staff does not have proper training.
Based on interviews conducted with Administrator, it revealed from her understanding Title 22 does not allow caregivers to change the bag. Interview revealed staff are not trained but are instructed to contact home health agency when needed regarding R1's colostomy bag. Based on interview revealed home health advised R1's primary care physician that due to R1's behavior and facility's concerns, R1 may need higher level of care.

Allegation: Staff is unable to communicate with resident due to language barrier.
Based on interviews conducted with S1 and S2, it revealed caregivers are able to communicate in English fluently. S1 and S2 are bilingual but are capable of communicating with residents in care. Interviews conducted with R2 revealed R2 does not have an issue communicating with staff regarding care. Interview conducted with R3 revealed R3 does not have an issue communicating with staff regarding care.

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

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

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
06/27/2023 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20230627082814

FACILITY NAME:	ONLY LOVE ELDERLY CARE HOME		FACILITY NUMBER:	345002979
ADMINISTRATOR:	LIM, KAREN		FACILITY TYPE:	740
ADDRESS:	4901 MELVIN DR		TELEPHONE:	(808) 228-0588
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS:	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:			TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff does not administer resident's prescribed medications.

INVESTIGATION FINDINGS:

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On 12/14/2023, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to deliver complaint findings for the allegations cited above. LPA met with Administrator, Karen Lim, and explained the purpose of the visit.

During the course of investigation, LPA conducted file review, staff interviews and resident interviews.

The result of the investigation is as follows.

Please continue on LIC 9099A-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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 4

Control Number 59-AS-20230627082814

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: ONLY LOVE ELDERLY CARE HOME	FACILITY NUMBER: 345002979
	VISIT DATE: 12/14/2023

NARRATIVE

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LIC 9099A-C...

Allegation: Staff does not administer resident's prescribed medications.
Based on file review conducted, facility does not keep medication administration record. Interviews conducted with R1 revealed R1 does not know if facility is administering medications in a timely manner or not. Interviews conducted with R2 revealed R2 does not remember if staff are giving her medications. Interview conducted with Administrator revealed Administrator does not have a concern with medication administration. Interview further revealed R1 has a long list of medication and supplements and is often confused if given or not.

Based on the information obtained during the course of investigation, LPA finds the cited allegations above to be (US)- 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.

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

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4