345920017-9-26-2024-59-AS-KHOS-DA6J6S-20241018064645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 345920017
Report Date: 09/26/2024
Date Signed: 09/26/2024 05:36:48 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
07/22/2024 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 59-AS-20240722223200

FACILITY NAME:	ILLINOIS HOME, LLC		FACILITY NUMBER:	345920017
ADMINISTRATOR:	SAMSON, DEXTER C.		FACILITY TYPE:	737
ADDRESS:	5035 ILLINOIS AVE		TELEPHONE:	(916) 206-9433
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	4	CENSUS: 4	DATE:	09/26/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Dexter C. Samson, Administrator		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Staff are physically abusing residents in care

Staff are not properly reporting incidents involving clients

INVESTIGATION FINDINGS:

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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 and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

** 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)

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Control Number 59-AS-20240722223200

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

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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)

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Control Number 59-AS-20240722223200

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

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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 staff member (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)

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Control Number 59-AS-20240722223200

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

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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.

Due to facility receiving a citation regarding the same violation in a separate inspection conducted on 9/26/2024, no additional citations will be issued regarding the allegation staff are physically abusing residents in care.

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, a deficiency is being cited on the attached 9099-D page.

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: 4 of 5

Control Number 59-AS-20240722223200

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 80061(b)(1)(E)	1 2 3 4 5 6 7	80061 Reporting Requirements (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will complete a statement of understanding regarding regulation 80061 and submit statement to LPA by POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure to report multiple incidents of resident injury and physical abuse to necessary agencies, which poses an immediate 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)

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