347003870-6-6-2023-59-AS-LMUZ-CSR2KY-20230612172843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003870
Report Date: 06/06/2023
Date Signed: 06/06/2023 03:36:54 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
02/27/2023 and conducted by Evaluator Lavinia Muscan

COMPLAINT CONTROL NUMBER: 59-AS-20230227091242

FACILITY NAME:	PALMERA CARE HOME		FACILITY NUMBER:	347003870
ADMINISTRATOR:	COSTEA, ANDREI		FACILITY TYPE:	740
ADDRESS:	7748 BLACK SAND WAY		TELEPHONE:	(916) 677-1078
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY:	6	CENSUS: 5	DATE:	06/06/2023
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Caregiver Shericka Powell		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff financially abused resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/6/23, Licensing Program Analysts (LPAs) Lavinia Muscan and Talwinder Bains arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Caregiver Shericka Powell. LPA Bains sopke to administrator Andrei Costea via phone at 3.20pm who gave permission to finish the visit with caregiver since he is out of town.

During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

**Report continued on 9099-C**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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 59-AS-20230227091242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PALMERA CARE HOME	FACILITY NUMBER: 347003870
	VISIT DATE: 06/06/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC 9099 ...

Allegation: Staff financially abused resident.

The Department investigated that staff financially abused resident (R1). An audit was conducted and found that the staff S1 was assisting R1 and other residents to withdraw money from their bank accounts on multiple occasions. S1 obtained access to R1s ATM card and PIN#. During interviews and facility records reviewed, it has been concluded that S1 used R1s ATM card 8 times to withdraw money without R1s permission. A police report was filed on 02/24/23. Police report indicated that S1 gained access to R1s bank card and used R1s ATM card 8 times to withdraw approximately $11,040. R1 and/or their responsible party did not give S1 permission nor were they aware that S1 was using their debit card. It was also found during the complaint investigation that S1 is not associated to this facility.

The preponderance of evidence has been that staff financially abused a resident therefore, the allegation is SUBSTANTIATED. In addition, citations are being issued today for S1 not being associated to this facility. Civil penalties are assessed in the amount of $500. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D.

Exit interview conducted. Appeal rights provided. Copy of the report provided to the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20230227091242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: PALMERA CARE HOME	FACILITY NUMBER: 347003870
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/07/2023 Section Cited CCR 87217(b)	1 2 3 4 5 6 7	87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by ...	1 2 3 4 5 6 7	Licensee agrees to submit statement of understanding and staff training of CCR regulation 87217(b) and submit proof to CCL by POC date 6/7/23.
	8 9 10 11 12 13 14	Based on records reviewed, it has been concluded that S1 got access of R1s debit card and PIN# and withdrew money from R1s bank account without R1s authorization and approval. This poses an immediate danger to health and safety of residents in care.	8 9 10 11 12 13 14
Type A 06/07/2023 Section Cited CCR 87355(e)(3)	1 2 3 4 5 6 7	87355 Criminal Record Clearance (e)All individuals subject to a criminal record review ... (b) shall prior to working, residing or volunteering in a licensed facility: (3)Request and be approved for a transfer of a criminal record exemption, ... the Department permits the individual to be employed, reside or be present at the facility. This regulation is not met as evidenced by ...	1 2 3 4 5 6 7	Licensee agrees to submit statement of understanding and staff training of CCR regulation 87355(e)(3) and submit proof to CCL by POC date 6/7/23.
	8 9 10 11 12 13 14	Based on records reviewed, it has been concluded that S1 was working at the facility but was not associated with the facility as required by this regulation which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	Immediate Civil Penalty of $500 has been issued.

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: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Lavinia Muscan	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3