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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347002908
Report Date: 11/05/2020
Date Signed: 11/06/2020 09:07:56 AM



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
04/21/2020 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200421095457
FACILITY NAME:REBECCA'S GUEST HOMEFACILITY NUMBER:
347002908
ADMINISTRATOR:MORRIS, REBECCA C.FACILITY TYPE:
740
ADDRESS:9458 HOSPENTHAL WAYTELEPHONE:
(916) 897-9397
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 3DATE:
11/05/2020
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Rebecca MorrisTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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LPA met with Administrator to deliver findings.

Based on the information learned during this complaint investigation, it was determined that another resident assisted R1 for transferring to and from a chair on multiple occassions. Based on information obtained for this investigation the facility has Insufficient staff to meet R1's needs. LPA Johnson conducted interviews with Administrator and residents LPA also reviewed medical records for R1. Based on these interviews and records the facility staffing of regular employees was insufficient for the number of identified needs of R1.

The facility has not been filling staff vacancies after firing three staff. This information was identified in a text message in documents supplied by the facility. Licensee returned from the Phillipines and did not back fill for the positions she terminated. The Licensee confirmed she is unable to pay staff because of the number of residents she is caring for. She stated that, "There is not enough money". Continued
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2020
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 3
Control Number 27-AS-20200421095457
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: REBECCA'S GUEST HOME
FACILITY NUMBER: 347002908
VISIT DATE: 11/05/2020
NARRATIVE
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The facility used another resident (R2) with a lack of knowledge of R1's needs, or any other potential risk of R1 medical issues. In a letter to the Licensee, R2 complained about R1 calling on R2 to assist him in his ADL.

R1 did sustain a fall at the facility on 3/28/2020. The facility contacted the family who told the facility to wait until they contact the Primary care doctor (PCP) for R1. On 3/29/2020, R1 and his sister refused to call 911. At 2:00pm on 3/29/2020, R1's PCP was called questions were asked of R1, the facility and the PCP told the facility that R1 had a torn ligament and prescribed an exercise plan and a telephone appointment on 4/2/2020. On 4/2/2020 a nurse from the VA hospital called, there were no notes from this phone visit. On 4/7/2020, 911 was called and R1 was transported to the VA hospital.

Medical records dated 4/7/2020 confirm that R1 had a fracture of the right humerus. R1 was not discharged back to the facility, R1 was discharged to his families home.

The facility did inform the VA hospital that R1's needs were greater than they could provide for and the facility requested a higher level of care. The facility sent text messages on 9/2/2019 and again on 3/31/2020. The facility did not refuse to pick up R1, however the VA hospital discharged R1 to the family.

As a result of this investigation, LPA finds allegation to be (S) 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 Administrator where LPA reviewed report. An electronic copy of the report was emailed to the facility to obtain a signature from the Administrator and emailed back to LPA to be filed.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20200421095457
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: REBECCA'S GUEST HOME
FACILITY NUMBER: 347002908
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2020
Section Cited
CCR
87411(a)
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87411(a)-87411 Personnel Requirements - General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met by: Based on observation and record review, the facility used another resident to assist another resident with transferring
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The Administrator/Licensee shall ensure staffing is sufficient in numbers and competent to meet the residents needs at all times (day and night). The administrator shall submit a memo of understanding regarding regulation 87411 to CCL by the POC due date.
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The Administrator/ Licensee allowed a resident of the facility without training assist R1 with transferring to and from the bed. This poses an immediate health and safety risk to the resident in care.
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The Administrator/Licensee must hire additional staff (day and night) and the facility staff must meet the requirements as noted above and required by RCFE Regulations. POC must be submitted by the POC due date.
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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.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) -26-4752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2020
LIC9099 (FAS) - (06/04)
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