347000443-4-12-2022-25-AS-MSEY-CDFLRY-20220413085952

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347000443
Report Date: 04/12/2022
Date Signed: 04/12/2022 03:20:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/17/2021 and conducted by Evaluator Kevin Mknelly

COMPLAINT CONTROL NUMBER: 25-AS-20211117151259

FACILITY NAME:	OAKS PRIVATE HOME CARE		FACILITY NUMBER:	347000443
ADMINISTRATOR:	TABB, LYDIA		FACILITY TYPE:	740
ADDRESS:	7016 LINCOLN OAKS DR.		TELEPHONE:	(916) 961-5232
CITY:	FAIR OAKS	STATE: CA	ZIP CODE:	95628
CAPACITY:	6	CENSUS: 4	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Lygea Tabacariu		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff forced resident to take medication
Staff made inappropriate comments towards resident
Staff yelled at residents
Staff left resident in soiled diaper for extended period of time
Staff handled resident in a rough manner
Staff did not administer resident’s medication as needed

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/12/22 at (time AM/PM), Licensing Program Analyst (LPA) Kevin Mknelly conducted an unannounced complaint investigation visit to deliver the findings for the above allegations and met with clinical staff. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Upon arrival, completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened with temperature at the facility.

LPA conducted records review and conducted extensive interviews.
LPA is unable to find and or meet the preponderance, per policy.

LPA Mknelly conducted inspection visits to the facility, interviewed two (2) residents who were also residents at the same time as R1 and reviewed R1’s medication records. The two residents interviewed

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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 2

Control Number 25-AS-20211117151259

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: OAKS PRIVATE HOME CARE	FACILITY NUMBER: 347000443
	VISIT DATE: 04/12/2022

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

both like the home and care provided to them . They also have never witnessed others mistreated at the home. LPA attempted to contact home health hospice staff familiar with R1’s care and information was not provided. The staff (S1) alleged to have conducted inappropriate actions resigned before they were able to be extensively interviewed, however, S1 denied any knowledge of residents mistreated at the facility when speaking with LPA on 11/23/21. The resident alleged to have been mistreated passed away at another care home before they were interviewed.

Therefore, the preponderance of evidence is not met and all allegations are unsubstantiated.

As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview with administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Kevin Mknelly	TELEPHONE: (209) 814-1925
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2