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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347000981
Report Date: 07/11/2024
Date Signed: 07/11/2024 05:01:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
02/01/2024 and conducted by Evaluator Victoria Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240201081455
FACILITY NAME:CARING FAMILIES-BV1FACILITY NUMBER:
347000981
ADMINISTRATOR:MACIAS, MICHELLEFACILITY TYPE:
740
ADDRESS:8712 BRAY VISTA WAYTELEPHONE:
(916) 685-0404
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lorrena GoodenoughTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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 Toilet, handwashing and bathing facilities are not being maintained in operating condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 7/11/24 at 12:50p. LPA was met by Caregiver Beatriz Hinojosa stating the purpose of the visit. Regarding allegation, “Toilet, handwashing and bathing facilities are not being maintained in operating condition. An interview with Bristol Hospice on 5/30/24 revealed that nothing was observed broken. An interview with LPA Ruth Wallace revealed the tub knob was working but needed a screw. S3 stated that the toilet lid was cracked, and was replaced. S1 stated the toilet was not broken but wobbly and just needed to be tightened. The Administrator admitted the toilet lid was cracked, and the screw for tub knob and the shower mat was all replaced. Based on interviews, observation of receipt, and admittance by Administrator the above allegation is SUBSTANTIATED. This finding means the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations (CCRs), Title 22, Div 6, Ch8, the deficiency is cited on the 9099D. A copy of their rights (LIC9058) provided and their signature acknowledges receipt of these rights. Exit interview conducted via telephone and a copy of report was provided via email and an electronic email read receipt confirms receiving these documents.
Substantiated
Estimated Days of Completion: 120
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
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 4
Control Number 27-AS-20240201081455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARING FAMILIES-BV1
FACILITY NUMBER: 347000981
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/11/2024
Section Cited
CCR
87303(a)
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Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors
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Licensee replaced the toilet, shower mat and repaired the tub knob. POC cleared prior to todays visit
Additionally, continue working with contractor to secure a test date for mold. The results shall be faxed to CCL upon completion.

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This requirement is not met as evidenced by:Based on admittance the licensee did not replace the items needing repair timely.
This poses a potential health and safety 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
02/01/2024 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20240201081455

FACILITY NAME:CARING FAMILIES-BV1FACILITY NUMBER:
347000981
ADMINISTRATOR:MACIAS, MICHELLEFACILITY TYPE:
740
ADDRESS:8712 BRAY VISTA WAYTELEPHONE:
(916) 685-0404
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
07/11/2024
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Lorrena GoodenoughTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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 Direct care staff not adequate to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
Food is being prepared off-site, not the facility premises. The preparation source shall meet all applicable requirements for commercial services.
Staff is not properly cleaning and sanitizing dishes and other utensils.
INVESTIGATION FINDINGS:
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Regarding allegation, “Direct care staff not adequate to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.” LPA conducted interviews on 5/30/24 with residents’ responsible parties. 3 of 4 responsible parties stated that additional staff is not necessary. S1 stated the residents are all cared for all the time. S2 stated that additional staff is not needed because the Administrator helps. S3 stated staff should not be leaving one facility to assist with the other. Administrator stated that she is unaware of any incident that occurred leaving the residents alone in the facility. Although there are cognitive issues, on 6/18/24, residents (R1-R6) all stated that they receive help from staff when needed. A review of the appraisals did not indicate special requirements for the residents care and supervision.

Regarding allegation, “Food is being prepared off-site, not the facility premises. The preparation source shall meet all applicable requirements for commercial services."
Unfounded
Estimated Days of Completion: 120
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20240201081455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CARING FAMILIES-BV1
FACILITY NUMBER: 347000981
VISIT DATE: 07/11/2024
NARRATIVE
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During the initial complaint visit on 2/3/24, LPA Ruth Wallace obtained a copy of a CA Food Handler Card effective 11/21/22 – 11/20/25 for witness#1 (W1). LPA Brown observed the food handler card that was in place prior to Community Care Licensing (CCL) receiving this complaint allegation. LPA Brown conducted interviews of R1-R5 on 6/18/24 which revealed that due to cognitive issues residents could not reasonably answer interview questions. However, R5 and R6 was able to state the food was good. An inquiry with Sutter Health revealed that for hospice residents, there are a lot of factors involved and it doesn’t equate to pounds although it is a decline, some are unable to be weighed, and a circumference measurement is taken of the left upper arm. The several factors involved are eating habits, diagnosis, edema, and diuretics. An interview with Bristol Hospice revealed that some residents on hospice has gained weight while others lost weight. And that this is not due to a food issue. An interview with LPA Ruth Wallace confirmed that the cook who prepares the main course for the meals has a current food handler certification. The food is prepared, frozen and transported to the facility. LPA Victoria Brown observed during visits on 5/30/24 and 6/18/24, that the main courses are frozen, labeled, dated, and contains instructions for cooking. S3 stated that unannounced visits are conducted to the kitchen and the facilities. All food is prepped according to all regulations. S2 stated the food is always a different variety. 1 of 4 of the responsible parties stated the quality of food has gone down in the past few months. The rest of the responsible parties stated the residents are given fresh fruits and vegetables as well as a variety of meals and there is not an issue with the food.

Regarding allegation, “Staff is not properly cleaning and sanitizing dishes and other utensils.
An interview with LPA Ruth Wallace revealed that the staff uses the dishwasher. S1 stated the dishwasher is always used. The responsible parties also stated the dishwasher is used by some and others washed the dishes by hand. Interviews on 5/30/24 and 6/18/24, all concur the dishes are not dirty nor broken and LPA Brown did not observe dirty dishes during the visits. S2 stated the dishwasher is used and there are no broken dishes. S3 stated the dishwasher has not needed repairs and it has its own water heater. The Administrator stated staff either wash the dishes or use the dishwasher.

Based on interviews, the preponderance of evidence standards has not been met. The allegations are deemed UNFOUNDED. “This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

An exit interview was conducted with Lorrena Goodenough via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4