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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345003004
Report Date: 05/23/2024
Date Signed: 05/23/2024 04:48:12 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
01/12/2024 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240112110717
FACILITY NAME:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(408) 218-5197
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
05/23/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Persida Pop, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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-Staff did not provide a proper eviction notice to resident or resident's authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 5/23/24, 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 and obtained documentation pertinent to the investigation.



***********************************************Continued on LIC9099-C****************************************************
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
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 5
Control Number 59-AS-20240112110717
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: 05/23/2024
NARRATIVE
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Allegation: Staff did not provide a proper eviction notice to resident or resident’s authorized representative.
On 12/30/23, resident (R1) and their responsible party received an unlawful eviction notice from the facility. The eviction notice did not provide a list of referral agencies or alternative housing options, as well as information about the resident’s right to file a complaint with the Department with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman. The Department obtained a copy of the notice on 1/19/24. The Department did not review the eviction notice prior to the facility providing a copy to R1 and their responsible party. Interview with Administrator indicated that they provided a copy to the Ombudsman and not the Department when the notice was issued. LPA advised the Licensee to submit any eviction notices to the Department and provided information on how to create a lawful eviction notice. A lawful eviction notice was created on 1/23/24 and provided to the Department.

Based on records reviewed and interviews conducted, 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, 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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 59-AS-20240112110717
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: 05/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited
HSC
1569.683(a)
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1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the notice to quit shall include all of the following: (2) Resources available to assist in identifying alternative housing and care options, including public and private referral services and case management organizations. (3) Information about the resident's right to file a complaint with the department regarding the eviction, with the name, address, and telephone number of the nearest office of community care licensing and the State Ombudsman.
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LPA provided licensee with information on how to complete a lawful eviction letter. Licensee provided updated and lawful letter to LPA on 1/19/23. Licensee agrees to submit a statement of understanding regarding what information should be included in an eviction letter by the POC due date of 6/6/24.
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This requirement is not met as evidenced by:
Based on interviews conducted and records reviewed, the facility did not include required information in R1’s eviction notice prior to serving notice, including housing resources and the resident’s rights to file a complaint with contact information of the nearest community care licensing office and the State Ombudsman, which poses a potential health, safety, and personal rights risk to residents in care.
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Type B
06/06/2024
Section Cited
CCR
87224(2)
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87224 Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days.

This requirement if not met as evidenced by:
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Licensee agrees to submit a statement of understanding regarding submitting a written report of eviction to the Department within five (5) days by POC due date 6/6/24.
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Based on interviews conducted and records reviewed, the facility did not provide the Department with a written report of R1’s eviction within five (5) days, which poses a potential health, safety, and personal rights risk to 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: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
01/12/2024 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240112110717

FACILITY NAME:LITTLE BROOK CARE HOMEFACILITY NUMBER:
345003004
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:8832 FAIR OAKS BLVDTELEPHONE:
(408) 218-5197
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 5DATE:
05/23/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Persida Pop, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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--Staff reported false medical emergency needs for resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 5/23/24, 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 and obtained documentation pertinent to the investigation.



*********************************************Continued on LIC9099-C*************************************************
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 59-AS-20240112110717
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: 05/23/2024
NARRATIVE
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Allegation: Staff reported false medical emergency needs for resident in care
According to interviews with the Administrator, staff (S1), and resident (R1’s) responsible party, the facility contacted emergency medical services (EMS) for R1 on 12/28/23. Interview with Administrator indicated that EMS was contacted due to R1 having diarrhea 4 times. Administrator indicated that R1’s responsible party suggested sending R1 to the hospital and R1 refused to go with EMS. Interview with R1’s responsible party indicated EMS contacted them indicating that they were contacted due to R1 having chronic diarrhea and not being able to give their own insulin. R1’s responsible party indicated that R1 refused to go with EMS. Interview with S1 indicated that R1 sometimes has diarrhea and has a prescription medication for diarrhea. S1 indicated that they do not recall why EMS was contacted on 12/28/23 but didn’t believe it was for diarrhea. S1 indicated that R1 refused to go with EMS.

According to EMS Prehospital Care Report, dated 12/28/23, they were dispatched to the facility due to the owner reporting that R1 was having chronic diarrhea for 3 weeks and new weakness. EMS responders contacted R1’s Power of Attorney (POA) who initially wanted R1 to be transported to the hospital due to R1 being too weak to self-administer insulin. EMS responders spoke with care staff and the facility owner, whom both indicated that R1 did not self-administer insulin that evening. R1’s account corroborated that they did not administer their insulin. Owner refused to give EMS responder’s their name and only stated that they are the Administrator. Administrator claimed that a care staff contacted EMS. Care staff denied this statement indicating that the Administrator contacted EMS. EMS responders then contacted the POA once more and, upon finding that the Administrator contacted EMS, the POA decided against transporting R1 to the hospital. EMS report indicated that R1’s vitals were taken and were within normal limits. EMS ended services with R1. The EMS report did not indicate that R1 refused services or that services were not needed.

Based on interviews conducted and documentation obtained, 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 allegation is UNSUBSTANTIATED. No deficiencies are being cited.

Exit interview conducted. A copy of the report was provided.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5