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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345003014
Report Date: 01/25/2024
Date Signed: 01/25/2024 02:58:00 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
01/22/2024 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240122135356
FACILITY NAME:LITTLE BROOK CARE HOME #3FACILITY NUMBER:
345003014
ADMINISTRATOR:POP, PERSIDAFACILITY TYPE:
740
ADDRESS:7300 NOB HILL DRTELEPHONE:
(916) 500-4512
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 4DATE:
01/25/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Persida Pop, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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-Facility is not providing medications as prescribed
-Facility is not keeping medications locked away
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood arrived unannounced at the care home today, 1/25/24, and met with Administrator, Persida Pop, to open and deliver findings into a complaint investigation regarding the above stated allegations.

During today's visit, LPA observed the keys to the medication cart hanging from the cart. LPA attempted to conduct a medication count. However, the facility does not have documentation for when each medication bottle was started and a medication count could not be conducted.

Based on observation and records reviewed, 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.
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: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
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 3
Control Number 59-AS-20240122135356
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 #3
FACILITY NUMBER: 345003014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/26/2024
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. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, 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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Licensee agrees document when each medication bottle is started for each resident and to complete a statement of understanding by the POC due date of 1/26/24.
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Based on observation and documentation reviewed, the facility did not ensure the start dates for each medication were documented and a medication count could not be conducted to ensure medications are being given as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type B
02/08/2024
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
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Licensee agrees to keep medication keys in a different location of the facility and will complete a statement of understanding by the POC due date 2/8/24.
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Based on observation, the facility did not ensure the keys were not hanging from the medication cart, 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: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240122135356
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 #3
FACILITY NUMBER: 345003014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
02/08/2024
Section Cited
CCR
87465(h)(6)
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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...
This requirement is not met as evidenced by:
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Licensee agrees to either complete Centrally Stored Medications Forms for each resident or update their electronic system to indicate all required information for each medication provided. Licensee agrees to submit a statement of understanding by the POC due date of 2/8/24.
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Based on observation and documentation reviewed, the facility did not ensure each resident had a completed Centrally Stored Medications Form, 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: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3