347002693-3-15-2021-27-AS-APEZ-C29L6X-20210420082926

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347002693
Report Date: 03/15/2021
Date Signed: 03/15/2021 03:37:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2020 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200807110149

FACILITY NAME:	YELLOWTAIL HOME CARE		FACILITY NUMBER:	347002693
ADMINISTRATOR:	LIU, YING (RUBY)		FACILITY TYPE:	740
ADDRESS:	8513 YELLOWTAIL WAY		TELEPHONE:	(415) 601-6107
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	6	CENSUS: 6	DATE:	03/15/2021
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Ying Ruby Liu- Licensee		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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- Not enough staff to meet resident's needs.
- Uncleared person assisting residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sarena Keosavang contacted the facility via telephone due to COVID-19 and pre-cautionary measures on 3/15/2021 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 8/7/2020. LPA spoke with Licensee, Ying Ruby Liu, and explained the purpose of the telephone call.
Throughout the course of the complaint investigation the Department conducted interviews and obtained pertinent documents relevant to the complaint.
Allegation: Uncleared person assisting residents. – Unsubstantiated.
According to Complainant, a resident (R1) fell off the wheelchair and was assisted by a non-employee who is not associated to the facility. LPA received statements from a total of 4 facility staff and 2 residents. Based on interview statements received, interviews with S1, S2, and S3 indicated there were no non-employees who frequently came to the facility to assist residents in care. Interviews with R1 and R2 were consistent with staffs’ statements.

***** Continue on LIC9099-C *****

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

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 27-AS-20200807110149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: YELLOWTAIL HOME CARE	FACILITY NUMBER: 347002693
	VISIT DATE: 03/15/2021

NARRATIVE

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Allegation: Not enough person assisting residents. – Unsubstantiated.

Based on interviews with residents, R1 and R2 indicated their needs are being met by facility staff. There are at least 2-3 caregivers working at the facility to assist residents in care.

Due to the information CCL finds the allegation 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.

An exit interview was conducted.

A copy of this report will be provided electronically to Licensee, Ying Ruby Liu, via email. Licensee to return a signed copy to CCL, a signed copy should be retained for facility records.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 03/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2021

LIC9099 (FAS) - (06/04)

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