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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 04:45:39 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
02/14/2024 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240214141242
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:
03:45 PM
MET WITH:Persida Pop, AdministratorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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-Facility is not providing medications as prescribed
-Facility staff interfered with resident's right to receive medical 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 allegations.

During the course of the investigation, LPA obtained documentation pertinent to the investigation, conducted a medication count for 3 residents, and conducted interviews.

Allegation: Facility is not providing medications as prescribed.
LPA conducted a medication count for residents (R1, R2 & R3), comparing the residents' medication lists on file with medication centrally stored for the residents. LPA observed four (4) medications for R1 that were over the amount documented and there were two (2) medications for R1 that were under the amount documented. LPA observed four (4) medications for R2 that were over the amount documented. LPA observed five (5) medications for R3 that were over the amount documented and there was one (1) medication that was under the amount documented.
********************************************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 6
Control Number 59-AS-20240214141242
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: Facility staff interfered with resident's right to receive medical care.
According to interviews with the Administrator and R1’s responsible party, R1 had a dialysis appointment scheduled 2/8/24. Interviews indicated that R1 goes to dialysis three times per week. Interviews indicated that R1 did not make their appointment on 2/8/24. Interview with the Administrator indicated that R1 did not make their dialysis appointment due to the road being blocked by SMUD for repairs to a power line. Administrator also stated that Regional Transit (RT) was unable to pick up R1 for the appointment due to SMUD blocking the roadway. Interview with SMUD indicated that they were conducting work on a broken pole from 2/4/24-2/8/24 and that tree work was involved as well. SMUD indicated that they have no record of the road being blocked or closed. According to documentation obtained from RT, a driver arrived at the care home on 2/8/24 at 9:49am to pick up R1 and take them to their dialysis appointment. Documentation indicated that the RT driver went to the facility door and was advised by facility staff that R1 was eating and needed more time. The RT driver attempted to call the facility phone and it went straight to voicemail. The RT driver attempted to contact the facility an additional time and left a voice message. Documentation indicated that the RT driver departed the facility at 9:56am. RT notes indicated that staff from the facility kept calling to rebook the trip and, when informed RT could not, staff would hang up. RT noted that they attempted to ask the facility staff if R1 still needed a return trip transport from the dialysis appointment and staff would hang up with no response. Documentation indicated that an RT driver arrived to pick up R1 from their dialysis appointment at 2:42pm, however, R1 was not at the appointment location for pick up. RT staff indicated that R1 has set appointments with RT for transport to and from their dialysis appointments three times per week. Administrator stated that the 2/8/24 dialysis appointment is the only one R1 missed.

Based on medication counts, records reviewed, and interviews conducted, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are 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 6
Control Number 59-AS-20240214141242
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 A
05/24/2024
Section Cited
CCR
87465(a)(4)
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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:
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Facility agrees to have all care staff providing medications sign a statement of understanding of job duties addressing medication management and to submit statements to LPA by the POC due date of 5/24/24. Facility will also complete bi-weekly audits of all medications for the next month and submit documentation to LPA.
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Based on medication count and records reviewed, the facility did not ensure that residents (R1, R2, & R3) were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
05/24/2024
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical(…)shall be developed by each facility. The plan shall encourage routine medical(…)care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical(…)needs. This includes transportation which may be limited to the nearest available medical(…)facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service.

This requirement is not met as evidenced by:
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Licensee agrees to create a plan ensuring all residents have transportation to medical and dental appointments and to submit plan to LPA by the POC due date of 5/24/24.
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Based on interviews conducted and records reviewed, the facility did not ensure R1 received transportation services to their dialysis appointment, which poses an immediate 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 6
Control Number 59-AS-20240214141242
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 A
05/24/2024
Section Cited
CCR
87468.1(a)(16)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services.

This requirement is not met as evidenced by:
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Licensee agrees to submit a statement of understanding and create a plan to ensure residents receive medical services by the POC due date of 5/24/24.
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Based on interviews conducted and records reviewed, the facility interfered with R1’s right to receive dialysis treatment on their scheduled appointment date, which poses an immediate 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: 4 of 6
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
02/14/2024 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240214141242

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: DATE:
05/23/2024
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:TIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
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9
-Facility is not providing resident with diabetic diet
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, XXX, and met with the Administrator, Persida Pop, to deliver complaint investigation findings into the above stated allegation.

During the course of the investigation, LPA obtained documentation pertinent to the investigation and conducted interviews.


**********************************************Continued 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: 5 of 6
Control Number 59-AS-20240214141242
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: Facility is not providing resident with diabetic diet
Interviews with the Administrator indicated that they grocery shop for the facility either every day or every other day. LPA observed resident (R1’s) diet restrictions posted on the refrigerator. The posting indicated that R1 is on a low sodium, sugar, potassium, and phosphorus diet. The posting also lists all the food items and drinks that R1 should not consume as part of the diet restrictions. Interviews with the Administrator and staff (S1 & S2) indicated that R1 was receiving a diabetic diet while they resided at the care home. Interviews indicated that R1 was provided sugar free and low sodium food.

Based on interviews conducted and documentation obtained, although the allegation may have happened or is 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: 6 of 6