345003004-10-2-2024-59-AS-MSEY-DA4LGF-20241016084438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345003004
Report Date: 10/02/2024
Date Signed: 10/02/2024 03:40:38 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
06/14/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240614145902

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:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Persida Pop, Administrator		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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-Staff did not provide resident’s medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 10/2/24, and met with the Administrator, Persida Pop, to deliver complaint investigation findings into the above stated allegation.

During the course of the investigation, LPA conducted interviews, a medications count, and obtained documentation pertinent to the investigation. 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. Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 9/25/24, no additional citations will be issued regarding allegation.

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. No citations are being issued today. 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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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
06/14/2024 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240614145902

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:	10/02/2024
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Persida Pop, Administrator		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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-Staff did not communicate with residents authorized representative.
-Staff not meeting resident’s hygiene needs.
-Staff did not obtain back up power for an extended amount of time.
-Staff does not ensure facility has enough food supply to provide for residents in care.
-Staff is having inappropriate interaction with resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home today, 10/2/24, 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 with staff and residents, as well as obtained documentation pertinent to the investigation.

Allegation: Staff did not communicate with residents authorized representative.
Facility provided documentation indicating that they were in communication with resident (R1’s) authorized representative between 5/25/24-5/28/24 regarding R1’s treatment for toenail that became infected after podiatrist cut toenails. Facility also provided documentation indicating that they were in communication with R1’s physician regarding medication for infection on 5/28/24. On 6/19/24, LPA spoke with R1 who had no concerns regarding their toe. LPA observed that staff had bandaged R1’s toe.
*****************************************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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

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 3

Control Number 59-AS-20240614145902

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: 10/02/2024

NARRATIVE

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Allegation: Staff not meeting resident’s hygiene needs
Interviews conducted with residents (R2, R3, R4, R5, R6, and R7) indicated that their hygiene needs are being met at the care home. Interviews with staff (S1, S2, S3, and S4) indicated that they believe all the residents' hygiene needs are being met. Interview with S1 indicated that they brush the residents’ teeth, as well as shower or sponge bath residents as scheduled. During visit conducted on 10/2/24, S2 was providing a sponge bath to R4. During visit conducted on 6/19/24, LPA observed that R1 appeared clean and groomed.

Allegation: Staff did not obtain back up power for an extended amount of time.
There are no Title 22 Regulations requiring the facility to obtain back up power, however, the complaint was regarding additional concerns arising from the power outage. Interviews with S1 and S2, who were present during the outage, indicated that there were no issues during the power outage, such as lack of food supply or emergency lighting. S1 and S2 indicated that there were no issues with the facility temperature during the power outage. S2 indicated that the facility purchased heaters so the facility would not be cold. Interviews with R3 and R4, who were present during the power outage, indicated that there were no issues that arose. Interview with Administrator indicated that they purchased a generated during the outage to ensure all residents had lightening and heat.

Allegation: Staff does not ensure facility has enough food supply to provide for residents in care.
At visits conducted on 6/19/24 and 10/2/24, LPA observed that care home to have the required (2) two-day perishable and (7) seven-day non-perishable food supply on hand. Interviews with R2, R3, R4, R5, R6, and R7 indicated that there is always plenty of food at the care home. Interviews with S1, S2, S3, and S4 indicated that the care home always has plenty of food on hand. S4 indicated that they always like to be prepared and order food before it gets too low.

Allegation: Staff is having inappropriate interaction with resident in care.
Interviews conducted with R2, R3, R4, R5, R6, and R7 indicated that they have never witnessed staff treating residents inappropriately. R2, R3, R4, R5, R6, and R7 indicated that all the staff treat them well. R2, R3, R4, R5, R6, and R7 indicated that all the staff treat them well and they have no concerns regarding the staff. Interviews with S1, S2, S3, and S4 indicated that they have never witnessed staff treating residents inappropriately.

Based on interviews conducted and observations, 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: 10/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024

LIC9099 (FAS) - (06/04)

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