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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003825
Report Date: 03/21/2022
Date Signed: 03/21/2022 03:46:25 PM



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
12/17/2021 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211217085849
FACILITY NAME:COZY HOME CAREFACILITY NUMBER:
347003825
ADMINISTRATOR:SOMORJAIFACILITY TYPE:
740
ADDRESS:5643 CLARK AVENUETELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: 2DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angelina Somarjai, Administrator TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff failed to report infectious disease to licensing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to deliver findings to a complaint received on 12/17/2021. LPA met with Judith Duncan, caregiver, who contacted the Administrator, Angelina Domarjai, who arrived around 2:55. pm to the facility. Caregiver on site confirmed there are (2) residents currently, and no residents are on hospice. Prior to initiating today's inspection, LPA completed required COVID-19 testing protocols and completed a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. Additionally, LPA was screened per Covid-19 precautionary measures upon entering the facility. LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N95 mask. LPA was informed (1) resident is at a medical appointment and (1) resident is napping in her room.

During the course of the investigation, LPA interviewed the Administrator, (2) caregivers and (3) family members of resident (R1). LPA also reviewed pertinent documentation for resident (R1), including, but not limited to: physician's reports, care plan, home health calendar of visits, after-visit medical appointment sumamries, text messages between facility Administrator and responsible person, and invoice of essential cleaning service.

The results of the investigation are as follows:

cont on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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-20211217085849
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: COZY HOME CARE
FACILITY NUMBER: 347003825
VISIT DATE: 03/21/2022
NARRATIVE
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Allegation: Facility staff failed to report infectious disease to licensing.

Administrator stated on 12/20/2021 that she did not submit an Unusual Incident/Injury Report (LIC624) to the Department following resident (R1) being diagnosed with scabies on/around September 2021. Administrator also indicated the scabies case was also not reported to local public health.

Administrator asserted that upon finding out about resident's scabies diagnosis, she immediately contacted an outside pest control company who disinfected the facility. Invoice reviewed shows that cleaning services were provided to the facility on 9/13/2021.

Based on information obtained, LPA finds the 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.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is issued on the 9099D page.

Exit interview. Copy of report and appeal rights printed and provided.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 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
12/17/2021 and conducted by Evaluator Sabrina Calzada
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20211217085849

FACILITY NAME:COZY HOME CAREFACILITY NUMBER:
347003825
ADMINISTRATOR:SOMORJAIFACILITY TYPE:
740
ADDRESS:5643 CLARK AVENUETELEPHONE:
(916) 283-4142
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Angelina Somarjai, Administrator TIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Facility staff did not seek medical attention in a timely manner
Resident death due to staff neglect.
INVESTIGATION FINDINGS:
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During the course LPA interviewed the Administrator, (2) caregivers and (3) family members of resident (R1). LPA also reviewed pertinent documentation for resident (R1), including, but not limited to: pre-appraisal, physician's reports, care plan, home health visits, after-visit medical appointment sumamries, text messages between facility Administrator and responsible person. The results of the investigation are as follows:

Allegation: Facility staff did not seek medical attention in a timely manner.

Complaint alleges that resident started itching in June or July and it took the facility months to find out resident had scabies.

Documentation shows resident (R1) moved in on/around 3/31/2021. Initial physician's report, appraisal and care plan do not indicate resident had scabies or a skin rash.

cont on 9099AC.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 25-AS-20211217085849
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: COZY HOME CARE
FACILITY NUMBER: 347003825
VISIT DATE: 03/21/2022
NARRATIVE
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Administrator stated that resident "came in with the itchiness" and was told by resident's responsible person (RP), that resident had a "terrible case of eczema", commenting "Yes, she (R1) would regularly itch" and staff saw scratches one month later. Administrator indicated RP would take resident "every week or every other week to the doctor due to her skin issues", and she and staff were told months after moving in by RP "we found out she has scabies".

(RP) stated that resident did not have any rash or skin condition when she moved in, but she got scabies after she had been there for a while, stating "it began with some spots and (R1) would scratch which led to big wounds." RP explained that resident's primary care doctor thought the antibiotics resident was taking for several UTI's were causing the rash and confirmed that the dermatologist did not diagnose the rash as scabies, initially- but prescribed different cremes to try, and that on the second visit, the dermatologist "did some scrapings" and diagnosed it then as scabies and prescribed Permethrin creme.

RP indicated that he did share the scabies diagnoses right away with facility staff, commenting he had "no idea where the scabies was coming from" as staff told him that no other residents had it. RP stated that home health was treating the scabies and used an anti-itch creme and that he would also put Permethrin creme on resident 1-2 times daily, and staff would put powder on; however, it wasn't completely effective, so the dermatologist prescribed oral ivermectin (pills) as a one-time application.

Home health records reviewed show resident was seen continuously, several times a week, by nurses and physical therapists while residing at the facility. Text messages show resident was scheduled for wound care on 5/25/2021 and 6/2/2021 and on 5/30/2021, care staff did not find the powder for the rash to be effective. After-visit medical summary notes from 7/13/2021 note that resident developed a rash and dermatitis as a side effect to treatment for her chronic UTI. Additional text messages note that resident had an appointment with a dermatologist on 8/20/2021 and on 9/6/2021. Administrator stated that resident was diagnosed with "bed bugs" on 8/20/2021 and returned to the doctor on 9/12/2021 and was diagnosed with scabies.
Administrator stated she got a call from a caregiver on 9/12/2021 that resident was diagnosed with scabies and was given another creme to treat it. Invoice shows a pest control company cleaned at the facility on 9/13/2021. Administrator stated she never received any medical paperwork showing resident was diagnosed with scabies but provided a physician order report, dated 9/18/2021, from a skilled nursing facility and Scabies is listed as one of resident's diagnoses.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

cont on 9099-A-C(1)...
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 25-AS-20211217085849
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: COZY HOME CARE
FACILITY NUMBER: 347003825
VISIT DATE: 03/21/2022
NARRATIVE
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Allegation: Resident death due to staff neglect.

Complaint alleges that resident became so sick from undiagnosed scabies she had to go to a skilled nursing in September and she died from blood disease caused by scabies.

Interviews conducted and documentation reviewed shows that resident was regularly being seen by the doctor and home health nurses for skin care issues, including wound care and rashes.

Text message dated 10/1/2021 documents that resident is "not doing well" and the "doctor says she is septic and is very very weak and still not eating". Administrator replied via text message asking RP what "Brought the infection on?" RP stated "they believe it started with a urinary tract infection, they are treating it with strong antibiotics".

LPA requested a copy of the death certificate during the investigation but was not provided with one.

Based on information obtained, LPA finds the allegation to be UNFOUNDED- meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview. Copy of report provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 25-AS-20211217085849
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: COZY HOME CARE
FACILITY NUMBER: 347003825
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2022
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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Licensee/Administrator agree to read Regulation 87211 and submit a signed statement by fax of its understanding by 4/4/2022.
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Based on interview conducted and documentation reviewed, the Licensee failed to ensure that an LIC624 was submitted within 7 days, or by 9/19/2021 (scabies diagnosed on 9/12/2021), which posed 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.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Sabrina CalzadaTELEPHONE: (510) 829-2133
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6