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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347001629
Report Date: 04/28/2022
Date Signed: 06/02/2022 10:56:12 AM

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
08/12/2021 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210812162045
FACILITY NAME:MARIA'S HOME CAREFACILITY NUMBER:
347001629
ADMINISTRATOR:ANDREI COSTEAFACILITY TYPE:
740
ADDRESS:5914 CANARY DRIVETELEPHONE:
(916) 344-5487
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Andrei Costea, LicenseeTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff failed to provide an adequate level of care that resulted in client injury.
Staff left premises, leaving residents without supervision.
Staff refused to give resident water.
Staff refused to take resident to bathroom.
Staff refused to give resident medication.
Staff do not treat residents with dignity.
Facility administrator not present at facility sufficient amount of hours.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jacob Williams met with Licensee, Andrei Costea, to conduct an inspection regarding a complaint investigation of violation for the above allegations. Prior to entering, LPA is COVID tested weekly, checks symptoms daily, used hand sanitizer and wore a surgical mask. In addition, LPA was screened for symptoms at entrance.

During the investigation, LPA toured the facility, interviewed facility residents, and obtained documentation pertinent to the investigation.


** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 6
Control Number 25-AS-20210812162045
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: MARIA'S HOME CARE
FACILITY NUMBER: 347001629
VISIT DATE: 04/28/2022
NARRATIVE
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Allegation: Facility staff failed to provide an adequate level of care that resulted in client injury.
During CCL's interview with R1, they stated they "always" had assistance when transferring from their wheelchair into bed. R1 said they tried to get into bed themself because they were tired. During the unassisted transfer they fell. They laid on the ground for approximately five minutes until they were picked up and placed into bed by S2. R1 had a history of falls. Multiple facility staff members and a home health employee indicated R1 could be stubborn at times and did things on thier own, even though R1 was fully aware they needed supervision and assistance with certain everyday tasks, such as transferring from his wheelchair into their bed.

Allegation: Staff left premises, leaving residents without supervision.
Through interviews conducted with residents R2, R3, R4, R5, and R6, all indicated that they have never once been left alone at facility without supervision.

Allegation: Staff refused to give resident water.
Through interviews conducted with residents R2, R3, R4, R5, and R6, all have indicated that staff have never refused to give them water.

Allegation: Staff refused to take resident to bathroom.
Through interviews conducted with residents R2, R3, R4, R5, and R6, the residents who need assistance with toileting stated that there has never been refusal to take them to the bathroom. The residents who do not need assistance stated that they have never witnessed staff refuse to take others to the bathroom.

Allegation: Staff refused to give resident medication.
Through interviews conducted with residents R2, R3, R4, R5, and R6, all indicated that they have never been refused medication, and that staff have never been responsible for them missing any doses of medication.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
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
08/12/2021 and conducted by Evaluator Jacob Williams
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210812162045

FACILITY NAME:MARIA'S HOME CAREFACILITY NUMBER:
347001629
ADMINISTRATOR:ANDREI COSTEAFACILITY TYPE:
740
ADDRESS:5914 CANARY DRIVETELEPHONE:
(916) 344-5487
CITY:NORTH HIGHLANDSSTATE: CAZIP CODE:
95660
CAPACITY:6CENSUS: 5DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Andrei Costea, LicenseeTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility staff failed to seek timely medical attention for client after unwitnessed fall.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jacob Williams met with Licensee, Andrei Costea, to conduct an inspection regarding a complaint investigation of violation for the above allegations. Prior to entering, LPA is COVID tested weekly, checks symptoms daily, used hand sanitizer and wore a surgical mask. In addition, LPA was screened for symptoms at entrance.

During the investigation, LPA toured the facility, interviewed facility staff and residents, and obtained documentation pertinent to the investigation.


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

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 25-AS-20210812162045
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: MARIA'S HOME CARE
FACILITY NUMBER: 347001629
VISIT DATE: 04/28/2022
NARRATIVE
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Allegation: Facility staff failed to seek timely medical attention for client after unwitnessed fall.
The department found that on 7/29/2021, at approximately 1429 hours, Home Health nurse, S1, called and spoke with the Veteran's Administration (VA) hospital staff. S1 informed VA hospital staff that R1 fell on 7/27/2021 and could not move their left leg. R1 stated that their hip hurts and the pain was caused by "hitting the floor. " S2 picked R1 up from off the ground after they found R1 on the floor of their bedroom. Hospital staff advised S1 to bring R1 to the hospital to be evaluated. During the departments interview with R1, they stated that they fell three times and did not go to the doctors for any of the falls. R1 was eventually taken to the VA hospital by their daughter on 8/6/2021 where it was discovered R1 had a femoral neck fracture. Licensee Andrei Costea and S2 both stated they did not call 911 after R1's fall because the fall did not look "too severe" and R1 appeared to feel "ok." They also thought R1 was enrolled in a hospice program while, in fact, R1 was enrolled in a home health program. S1 said that facility staff knew R1 was not on hospice care because R1 was on a therapy program. S1 informed CCL both S2 and Licensee were aware of R1's hip and leg pain. S2 told S1 that it was "not their responsibility" to take R1 to get x-rays. S2 was the staff member who said "no" to taking R1 to the hospital for x-rays. During a phone interview with R1's primary care physician, CCL asked if it was possible for an elderly individual to walk, with the aid of a walker, and still participate in physical therapy with a broken hip; the primary care physician stated it is not unusual for people to act "stoic" and attempt to "downplay" the pain they feel. Primary care physician said it was "possible" for an elderly person with a hip fracture to walk, and they have seen it happen before. The Doctor also described R1 as "stoic" and said they sometimes downplay their pain when asked by medical staff of how they're feeling."

As a result of this investigation, LPA finds allegation to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview was conducted with Licensee and a copy of this report was provided to the facility. The signature of Licensee on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 25-AS-20210812162045
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: MARIA'S HOME CARE
FACILITY NUMBER: 347001629
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
80075(a)
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Health Related Services (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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Licensee is to submit a plan to CCL for what what action to take after an incident occurs in which a client could have sustained an injury. Plan should be submitted within one day (04/29/2022).
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Based on statements and medical documents obtained, Licensee did not provide arrangements nor transportation to medical treatment to one (1) client which poses an immediate health and safety risk to client 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: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20210812162045
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: MARIA'S HOME CARE
FACILITY NUMBER: 347001629
VISIT DATE: 04/28/2022
NARRATIVE
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Allegation: Staff do not treat residents with dignity.
Through interviews conducted with residents R2, R3, R4, R5, and R6, all indicated that they are treated well by staff, with dignity and respect.

Allegation: Facility administrator not present at facility sufficient amount of hours.
Through interviews conducted with residents R2, R3, R4, R5, and R6, it is determined that Administrator/Licensee visits roughly once per week, sometimes more. Facility appears to be running well and is clean and the residents are content, so LPA is determining that this amount of time is sufficient in this case.

Based on interviews conducted by LPA, observations during inspection, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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 was conducted with Licensee and a copy of this report was provided to the facility. The signature of Licensee on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Jacob Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6