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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003582
Report Date: 02/04/2025
Date Signed: 02/04/2025 11:28:32 AM

Unsubstantiated


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
04/17/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240417144857
FACILITY NAME:JONES FAMILY HOMEFACILITY NUMBER:
347003582
ADMINISTRATOR:RICHARDS, SHIRLEYFACILITY TYPE:
735
ADDRESS:4275 ARDWELL WAYTELEPHONE:
(916) 424-8209
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 4DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Jennie Mcdavid TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Staff did not ensure resident is provided clean clothing.
Staff did not ensure resident bathing needs were met.
INVESTIGATION FINDINGS:
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5
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13
On 02/04/25 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with caregiver Jennie Mcdavid and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 4. A brief interview with conducted with via telephone with administrator Shirley Richards.

It was alleged that staff did not ensure resident is provided with clean clothing and did not ensure resident bathing needs were met. The investigation included observations, a review of records, and interviews with staff and residents. On 04/25/2024, LPA noted that Client 1 (C1) was not present in the facility and was informed that C1 had moved to another facility. On the same date, the LPA observed two other clients at the facility, both dressed in clean clothing and with no hygiene concerns noted during the visit. Another visit on 07/18/2024, LPA observed four clients, all appearing to have clean clothing and good hygiene.

Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 5
Control Number 27-AS-20240417144857
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: JONES FAMILY HOME
FACILITY NUMBER: 347003582
VISIT DATE: 02/04/2025
NARRATIVE
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 During interviews, three staff members reported that C1 required frequent reminders to change clothes and that staff had encouraged C1 to change, but C1 refused. Staff denied the allegations. In interviews with 5 out of 5 residents, all confirmed that staff remind them to shower and provide them with clean clothing. A review of C1’s Individual Program Plan (IPP) dated 11/03/23 highlighted that C1 exhibits specific behaviors when asked to complete hygiene tasks. Facility records further show that C1 was reminded on multiple occasions to complete hygiene tasks such as showering and changing clothes. Based statements obtained during the investigation process, LPA was unable to corroborate the allegations.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation are UNSUBSTANTIATED means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/17/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240417144857

FACILITY NAME:JONES FAMILY HOMEFACILITY NUMBER:
347003582
ADMINISTRATOR:RICHARDS, SHIRLEYFACILITY TYPE:
735
ADDRESS:4275 ARDWELL WAYTELEPHONE:
(916) 424-8209
CITY:SACRAMENTOSTATE: CAZIP CODE:
95823
CAPACITY:6CENSUS: 4DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Jennie Mcdavid TIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not address a change in resident's health condition in a timely manner.
Staff did not seek timely medical attention for resident.
INVESTIGATION FINDINGS:
1
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3
4
5
6
7
8
9
10
11
12
13
On 02/04/25 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with caregiver Jennie Mcdavid and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 4. A brief interview with conducted with via telephone with administrator Shirley Richards.

It was alleged that the staff did not address a change in the resident health condition in a timely manner, and facility did not seek appropriate medical attention for the resident. The investigation involved interviews with staff and a review of records. LPA Lee interviewed three facility staff members, all of whom stated that client 1 (C1) had multiple telephone appointments and 2 emergency room visits to address C1's health concerns. According to the facility records, C1 moved into the facility on 10/23/23 and had a physician’s visit on 10/25/23. During the visit, C1’s weight was recorded as 107 pounds and 6.4 ounces.

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 5
Control Number 27-AS-20240417144857
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: JONES FAMILY HOME
FACILITY NUMBER: 347003582
VISIT DATE: 02/04/2025
NARRATIVE
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 C1’s caregiver, Staff 1 (S1), was listed as the primary contact person for C1, with a contact number on file C1’s PCP file. On 11/30/23, C1 had a telephone appointment where C1 were diagnosed with an upper respiratory infection. On 12/12/23 at 4:14 PM, C1’s primary care physician (PCP) called and left a message. On the same day, a request for a Levothyroxine refill was declined because C1 had not completed the necessary testing requested by the PCP. On 12/13/23, a second attempt was made to contact C1 by phone, but the call was unsuccessful, so a message was sent via Kaiser portal requesting that C1 book a telephone appointment. Another message was sent on 12/14/23 at 9:46 AM regarding C1’s medication, as previous phone attempts had been unsuccessful. On 12/15/23, C1 had a scheduled telephone appointment but did not attend ("no-show"). Despite phone calls being made and a message being left, there was no response. On 12/27/23 at 11:56 AM, a message was sent to C1 after the PCP attempted to contact C1 by phone without success.

On 01/15/24, C1 was admitted to the Kaiser Emergency Room for a cough and shortness of breath, where C1 was diagnosed with an acute upper respiratory infection (URI). The medical record from that visit indicated C1 had been experiencing a productive cough with yellow phlegm and difficulty breathing upon exertion for about a week. A follow-up appointment was scheduled for 01/16/24 at 12:00 PM, but C1 missed the appointment. At 12:09 PM, the PCP called C1 but received no answer, leaving a message. On 01/30/24 at 10:45 AM, C1 had another scheduled telephone appointment but was once again a “no-show.” Despite multiple attempts at 10:56 AM, 11:25 AM, and 11:44 AM to reach C1 and leaving messages, there was no response. On 02/01/24, C1 was admitted to the hospital with a diagnosis of septic shock caused by empyema and was placed in the ICU. C1’s chest CT revealed a large left peripheral enhancing fluid collection with an air-fluid level and debris. A catheter was placed, and intrapleural fibrinolytics were started. C1 was discharged on 02/16/24 to a rehabilitation facility. Based on the medical records and multiple missed appointments, it appears the facility did not ensure C1’s health condition was addressed promptly or that timely medical attention was sought. The repeated unsuccessful attempts by C1’s PCP to contact them, as well as the missed appointments, suggest that the necessary steps were not taken in a timely manner.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Jennie Mcdavid and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240417144857
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: JONES FAMILY HOME
FACILITY NUMBER: 347003582
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2025
Section Cited
CCR
80075(a)
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80075 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 evidence by:
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Licensee agrees to conduct an outside training from a third party for health related services training for all staff, by POC Date 02/12/25. Administrator agrees to email training materials used and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC end of day 5:00 PM.
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Based on interviews and records review, the administrator did not ensure that a client received medical attention timely by not showing up for scheduled telephone appointments which posed an immediately health and safety to clients in care.
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9
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14
Licensee will also provide LPA Lee ad statement of reviewing and acknowledgement of understanding of the regulation cited.

Type A
02/12/2025
Section Cited
CCR
85075.4(a)
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85075.4 Observation of the Client
(a) The licensee shall regularly observe each client for changes in physical, mental, emotional, and social functioning.

This requirement was not met as evidence by:
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Licensee agrees to conduct an outside training from a third party for health related services training for all staff, by POC Date 02/12/25. Administrator agrees to email training materials used and sign in and out sheet to LPA Lee at pang.lee@dss.ca.gov by POC end of day 5:00 PM
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Based on interviews and records review, the administrator did not ensure that a client’s change in health condition was addressed in a timely manner since PCP was unable to reach the client to discuss medications and appointments which posed an immediately health and safety to clients in care.
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Licensee will also provide LPA Lee a statement of reviewing and acknowledgement of understanding of the regulation cited.

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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5