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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003844
Report Date: 03/03/2023
Date Signed: 03/03/2023 03:24:05 PM

Document Has Been Signed on 03/03/2023 03:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:CRUZ HOMEFACILITY NUMBER:
347003844
ADMINISTRATOR:LEAGUE, LILIAFACILITY TYPE:
735
ADDRESS:9004 MOSELY CTTELEPHONE:
(916) 525-1423
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 6CENSUS: 6DATE:
03/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Bernardo CruzTIME COMPLETED:
03:40 PM
NARRATIVE
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On 3-3-23 at 1:06pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding an incident which occurred on 2-6-23 and reported to licensing on 2-6-23. LPA met with Licensee Bernardo Cruz and explained the purpose of the visit. LPA reviewed incident report dated 2-6-23 and conducted interview with Licensee. LPA also reviewed individualized program plan (IPP) for resident1 (R1) and care note for R1 dated 2-6-23. Based on record review and interview, it was determined that R1 engaged in aggressive behavior towards R2 on 2-6-23 at 6:30am which included R1 demonstrating behavior of attacking R2 while R2 was sleeping. R2 sustained scratches to forehead and face.

Based on interviews and record reviews, R1 was successfully redirected after several prompts and behavior was de-escalated. Based on interview and record review, R2 was assisted to local urgent care by staff on 2-6-23 and sent to local hospital with advisement by urgent care on 2-6-23. Record review and interview revealed no serious injury occurred and R2 was sent back to facility on 2-6-23 at approximately 6:00pm with new medication orders. Interview conducted revealed this incident was not reported to ombudsman and local law enforcement per regulatory requirements. Additionally, based on interview, it was determined that Licensee was unaware of reporting requirements which led to deficient reporting procedures.

As a result of today's case management, deficiencies are cited based on Title 22, Division 6. A civil penalty in the amount of $250 is issued in addition to citation due to repeat violation within 12-month period. An exit interview was conducted with Bernardo Cruz and a copy of this report was left with Bernardo.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/03/2023 03:24 PM - It Cannot Be Edited


Created By: Michael Bilger On 03/03/2023 at 02:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CRUZ HOME
FACILITY NUMBER: 347003844

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
80061(d)

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Reporting requirements. (d) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency...This requirement was not met as evidenced by:
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Licensee will read regulation 80061 and submit a signed declaration of understanding to LPA by POC due date.
Licensee will complete training and ensure all staff training on reporting requirements. Proof of completed training to be submitted to LPA by POC due date.
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Based on interview and record review, licensee did not ensure an incident report involving dependent adult abuse between R1 and R2 was reported to ombudsman and local law enforcement. This posed a potential health, safety, and resident rights risk to residents in care.
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Type B
03/17/2023
Section Cited
CCR80064(a)(3)

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Administrator Qualification and Duties. (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement was not met as evidenced by:
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Licensee will read regulation on reporting requirements pertaining to known or suspected abuse and submit a signed declaration of understanding to LPA by POC due date. Regulation is reference in Section 80061 of Title 22, Division 6, Chapter 1.
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Based on interview, it was revealed Licensee was not aware of full reporting requirements in regards to known or suspected abuse. This poses a potential health, safety, and resident rights 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:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2023


LIC809 (FAS) - (06/04)
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