345003004-9-25-2024-59-AS-MSEY-DA2P68-20241014110156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345003004
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:17:58 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
05/24/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240524095425

FACILITY NAME:	LITTLE BROOK CARE HOME		FACILITY NUMBER:	345003004
ADMINISTRATOR:	POP, PERSIDA		FACILITY TYPE:	740
ADDRESS:	8832 FAIR OAKS BLVD		TELEPHONE:	(279) 289-6907
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Persida Pop, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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-Facility is not providing medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 9/25/24, and met with the Administrator, Persida Pop, to deliver complaint investigation findings into the above stated allegation.

During the course of the investigation, LPA reviewed documentation and conducted a medication count.
Allegation: Facility is not providing medications as prescribed.
During a visit conducted on 6/19/24, LPA conducted a medication count for resident (R1) comparing the resident's medication lists on file with the medication centrally stored for the resident. LPA observed three (3) medications for R1 that were over the amount documented.

Based on a medication count and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D page.

Exit interview conducted. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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 4

Control Number 59-AS-20240524095425

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: LITTLE BROOK CARE HOME	FACILITY NUMBER: 345003004
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/26/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has implemented medication counts and provided the most recent medication count documentation to LPA during visit. Facility agrees to complete bi-weekly audits of all medications for the next month and submit documentation to LPA.
	8 9 10 11 12 13 14	Based on medication count and records reviewed, the facility did not ensure that resident (R1) was receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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
05/24/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240524095425

FACILITY NAME:	LITTLE BROOK CARE HOME		FACILITY NUMBER:	345003004
ADMINISTRATOR:	POP, PERSIDA		FACILITY TYPE:	740
ADDRESS:	8832 FAIR OAKS BLVD		TELEPHONE:	(279) 289-6907
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 6	DATE:	09/25/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Persida Pop, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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-Staff do not treat residents with respect
-Staff are on drugs while providing care to the residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 9/25/24, and met with the Administrator, Persida Pop, to deliver complaint investigation findings into the above stated allegations.

During the course of the investigation, LPA conducted interviews.
Allegation: Staff do not treat residents with respect.
Interviews conducted with residents (R1, R2, and R3) and staff (S1 and S2) indicated that staff treat residents with respect. Interviews with R1, R2, R3, and resident (R5) indicated that they have never witnessed or experienced abuse in the care home. Interviews with S1 and S2 indicated that they have never witnessed staff abusing residents in care.

***********************************************Continued on LIC9099-C**************************************************

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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-20240524095425

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: LITTLE BROOK CARE HOME	FACILITY NUMBER: 345003004
	VISIT DATE: 09/25/2024

NARRATIVE

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Allegation: Staff are on drugs while providing care to the residents.
Interviews conducted with S1 and S2 indicated that they have never witnessed staff using drugs or having substance intoxication from drugs while working in the care home. R1, R2, R3, resident (R4), and R5 did not have any concerns about the staff in the care home.

Based on interviews conducted, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4