<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345920017
Report Date: 09/26/2024
Date Signed: 09/26/2024 05:26:14 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
05/28/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240528131605
FACILITY NAME:ILLINOIS HOME, LLCFACILITY NUMBER:
345920017
ADMINISTRATOR:SAMSON, DEXTER C.FACILITY TYPE:
737
ADDRESS:5035 ILLINOIS AVETELEPHONE:
(916) 206-9433
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:4CENSUS: 4DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Dexter C. Samson, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are mismanaging residents' medications

Residents are sustaining unexplained injuries

Residents are not receiving adequate food services

Facility staff are not adequately trained
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Michael Hood and Cassie Mikkelson arrived at the facility and met with Administrator, Dexter Samson, to deliver findings into the complaint allegations listed above.

During the investigation, the Department conducted interviews, toured the facility, conducted a medication count, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff are mismanaging residents' medications

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 9
Control Number 59-AS-20240528131605
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: ILLINOIS HOME, LLC
FACILITY NUMBER: 345920017
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Multiple relevant parties reported facility staff mismanaging residents’ medications. One relevant party reported that facility is missing medical records regarding medications for resident (R1), and relevant party identified medication errors for R1. Another relevant party reported that PRN medication is being used to sedate residents and facility is falsifying documentation to justify administering PRN medication. Report also indicated that facility frequently misses administering medications without reporting.

During a visit conducted on 6/04/2024, LPA Hood conducted a medication count for residents R1, R2, R3, and R4 comparing the resident’s Centrally Stored Medication Form (CSMF) with medications centrally stored for the residents. LPA did not observe any errors when comparing each resident’s CSMF with the medications counted.

Interview with staff members (S3 and S5) indicated that PRN medication for resident (R4) has gone missing or has been misplaced. Interview with staff member (S7) indicated that there was a medication error regarding insulin.

LPA received an Alta California Regional Center Special Incident Report (SIR) dated 4/29/2024 stating the following information: "On 4/29/2024, [staff member S13] noticed that another [staff member S12] administered 6 units of [medication] to [resident R3] based on [R3's] sliding scale instead of [medication] at bedtime on 4/28/2024." Interviews with Administrator indicated that S12 has not worked at the facility since incident.

Allegation: Residents are sustaining unexplained injuries


** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 59-AS-20240528131605
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: ILLINOIS HOME, LLC
FACILITY NUMBER: 345920017
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Multiple relevant parties reported residents sustaining unexplained injuries. One relevant party reported that R1 is sustaining unexplained bruises and believes bruises have been sustained by rough handling from staff. Another relevant party reported that resident (R2) sustained circular bracelet marks around their wrist, and R2 expressed pain from the marks. Another relevant party reported that facility has a staff member who hits the residents in care and facility is knowingly covering up the incidents of physical abuse.

Interview with local long-term care ombudsman (LTCO) indicated that the circular marks around R2’s wrists were old injuries that do not match what was reported by the facility. Interview with Alta California Regional Center (ACRC) representative confirmed LTCO’s statement that R2’s injuries sustained on their wrists were older injuries and did not match what was reported by facility.

Interview with regional center representative indicated that injuries were documented on a shared information report and should have been reported as a Special Incident Report (SIR) to regional center and CCLD. LPA Hood observed R2’s injuries during the investigation and received shared information report on 8/01/2024 indicating that injury was observed on 7/25/2024.

LPA Hood observed a shared information report on file for R1 dated 12/14/2023, indicating that R1 was observed to have sustained a bruise on top of their right foot with no known incident to account for injury. LPA Hood observed a shared information report on file for R1 dated 2/16/2024 indicating that R1 twisted their ankle while exiting the facility van. Report indicates that PRN was given for pain and R1 was at baseline. LPA Hood observed a shared information report on file for R1 dated 4/23/2024 indicating that R1 sustained an inch long bruise on their forearm with no unusual incident observed regarding R1 sustaining injury. LPA Hood observed a shared information report on file for R1 dated 5/7/2024 indicating R1 sustained a bruise on stomach and right arm. Report does not indicate any incidents associated to R1 sustaining injury.

Interview with staff members S3 and S5 indicated that they witnessed staff member (S1) slap resident (R3) on the hand. Interview with S3 and S5 indicated that the incident was reported to Acting Administrator (S8) and staff were told by S8 not to lie about other staff. S3 and S5 stated that R3 reported that S1 hit them to S8, but statement from R3 was ignored by S8.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 59-AS-20240528131605
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: ILLINOIS HOME, LLC
FACILITY NUMBER: 345920017
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 Interview with S5 indicated that they witnessed multiple incidents in which S1 hit multiple residents, including R3. Interviews with S3 and staff member (S6) indicated that S1 used their body to restrain residents R1 and R4. S3 stated that S1 restrained residents to draw blood. S6 stated that S1 restrained R1 to apply an ice pack to their ankle regarding incident when R1 twisted their ankle. Interview with S6 indicated that R1 should have been transferred to a hospital regarding ankle injury, but facility never took R1 to the hospital for injury. Interview with staff member (S4) indicated that R3 appears to not want to be around S1.

Interviews with S4 and S6 indicated that they witnessed staff member (S2) kick resident R3 under a table. Interview with S3, S4, and S6 indicated that R3 appears to be intimidated by S2. Interview with staff member (S5) indicated that they witnessed multiple incidents in which S2 hit multiple residents, including R3. S5 stated that they witnessed R3 hit S1 in the stomach with S2 witnessing the incident. S5 stated that S2 hit and shoved R3 in response to R3 hitting S1. Interview with S5 indicated that they witnessed S2 flicking R4’s ear. S6 stated they were informed about S2 flicking R4’s ear. S5 stated that R4 has sustained injuries to their ear, causing their ear to be purple and black.

Interview with staff members S3 and S4 indicated that resident (R3) sustained a black eye. S4 questioned the origin of R3’s injury due to abuse sustained by staff member (S2). Interview with S6 indicated that they have observed a decrease in R1 sustaining bruises since S1 and S2 were removed from the schedule. S6 reported that R3 had a fall in which they believe S2 was responsible. S6 stated that they reported witnessed physical abuse to S8 and Administrator Dexter Samson but was unaware of the outcome. Both S5 and S6 reported R4 sustaining a large bruise on their back. They were both informed that R4 sustained a fall, but both S5 and S6 question the origin of the injury.

Interview with S5 indicated that they have reported multiple incidents of abuse from staff towards residents to facility Administrators and has observed that the Administrators do not seem to care regarding reporting. Interviews with S4 and S6 stated that they have been told to not report incidents regarding residents to outside agencies.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 59-AS-20240528131605
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: ILLINOIS HOME, LLC
FACILITY NUMBER: 345920017
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interviews conducted with S8 and Administrator Samson indicated that they have never received any reports from any staff indicating that they witnessed S1 or S2 being physically abusive to the residents in care.

Allegation: Residents are not receiving adequate food services

Relevant party reported that R1 has not been receiving three meals a day and R1 has been either overfed or underfed by staff. Interview with staff S3 and S4 indicated that food is withheld from R1 and used to taunt R1 by staff S2, S9, and S11 to control R1’s behaviors. S3 stated that R1 will sometimes not eat because they do not like the food offered to them and no other options will be offered to R1 by the facility. Interviews with staff S4, S5, and S6 indicated that the facility withholds food from resident R1.

During visit conducted on 8/01/2024, LPA Hood observed multiple expired food items in a storage outside of the kitchen area on the premises. Facility removed expired food items during visit and LPA did not observe any other expired food items on the premises.

Allegation: Facility staff are not adequately trained

Multiple relevant parties reported that staff are inadequately trained. One relevant party reported that facility is forging documentation for staff training and staff are not actually completing the training they are signing off on. Another relevant party reported that staff are supposed to be DSP1, DSP2 and RBT within 1 year of employment, and the current staff members didn’t meet the regulations, with one staff only having DSP 1 and working more than a year.

LPA Hood received a Facility Action Report from ACRC dated 8/7/2024 indicating that 4 direct support staff did not receive Registered Behavioral Technical Certification within one year of their hire dates.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 59-AS-20240528131605
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: ILLINOIS HOME, LLC
FACILITY NUMBER: 345920017
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Hood received information regarding a visit conducted by Department of Developmental Services (DDS) on 9/24/2024 indicating that one (1) of seven (7) staff hired on 8/7/2023 had not completed initial 40-hours of RBT training.

During visit conducted on 6/04/2024, LPA Hood reviewed staff file for S1. LPA observed that S1 was missing training for orientation per Title 22 for Health and Emergency Procedure and Mass Casualty.

Interview with staff members S3, S4, S5, and S6 indicated that facility is not providing training to staff. S3, S4, S5, and S6 stated that training documentation was given to them to sign off on without being given the training documented.

Based on interviews conducted, observations, 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. An immediate civil penalty of $500 is assessed for today’s date for a violation that the Department determines resulted in the injury of a resident per Health and Safety Code §1548.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 9
Control Number 59-AS-20240528131605
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: ILLINOIS HOME, LLC
FACILITY NUMBER: 345920017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2024
Section Cited
CCR
80075(b)
1
2
3
4
5
6
7
80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility completed follow-up training with RN consultant following incident and provided LPA documentation regarding regular medication training following incident. LPA will clear deficiency at the conclusion of this investigation.
8
9
10
11
12
13
14
Based on reported incident, the facility did not ensure that client's medications were administered correctly, which poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type A
09/27/2024
Section Cited
CCR
80072(a)(3)
1
2
3
4
5
6
7
80072 Personal Rights (a) (...) each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature (...). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility will complete a statement of understanding regarding regulation 80072 and submit statement to LPA by POC due date. An immediate civil penalty of $500 is assessed for a violation that the Department determines resulted in the injury of a resident.
8
9
10
11
12
13
14
Based on interviews conducted, the facility did not ensure residents were free of unusual punishment or abuse when staff S1 and S2 physically abused multiple residents and R1 was taunted with food by multiple staff, which poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 59-AS-20240528131605
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: ILLINOIS HOME, LLC
FACILITY NUMBER: 345920017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
80012(a)
1
2
3
4
5
6
7
80012 False Claims (a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility will complete a statement of understanding regarding regulation 80012 and submit statement to LPA by POC due date.
8
9
10
11
12
13
14
Based on interviews conducted, the facility disseminated false claims when having staff sign off on training that wasn't actually completed and discouraging staff from reporting incidents to appropriate agencies, which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
10/11/2024
Section Cited
CCR
80076
1
2
3
4
5
6
7
80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. (...) All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility removed expired food items during investigation. LPA will clear deficiency at the conclusion of this investigation.
8
9
10
11
12
13
14
Based on LPA's observations, the facility did not ensure that there were not any expired food items on the premises, which poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 59-AS-20240528131605
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: ILLINOIS HOME, LLC
FACILITY NUMBER: 345920017
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
89965(h)
1
2
3
4
5
6
7
89965 Personnel Requirements In addition to Sections 80065, 84065 and 85065, the following shall apply: (h) In addition to any other required training, within the first 40 hours of employment, all direct care staff shall complete minimum of 32 hours of on-site orientation. The on-site orientation includes the training required pursuant to Sections 80065(f) and 84065(i) as applicable to the facility's licensure type, and shall also address the following: (...) This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility will include missing orientation training items for future employees. Facility will complete a statement of understanding regarding regulation 89965 and submit statement to LPA by POC due date.
8
9
10
11
12
13
14
Based on records reviewed, the facility did not ensure that staff member (S1) completed Health and Emergency Procedure and Mass Casualty training for orientation training, which poses a potential 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 9