347003936-3-7-2024-27-AS-KHOS-D3PPAG-20240325110843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003936
Report Date: 03/07/2024
Date Signed: 03/07/2024 11:55:16 AM

Substantiated

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
03/05/2024 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20240305091118

FACILITY NAME:	TENDER HOME SENIOR CARE		FACILITY NUMBER:	347003936
ADMINISTRATOR:	MARINOVA, VALENTINA		FACILITY TYPE:	740
ADDRESS:	3499 PONZI COURT		TELEPHONE:	(916) 851-1888
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95670
CAPACITY:	6	CENSUS: 5	DATE:	03/07/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Valentina Marinova		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff forced resident to stay in bed.
Staff does not treat resident with respect.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an initial complaint investigation of the above-mentioned allegations on 3/7/24 at 8:45am. LPA met with Licensee Valentina Marinova and stated the purpose of the visit. LPA requested a copy of the Register of residents and Personnel Report (LIC500) with contact numbers for staff. LPA observed 1 caregiver during this visit assisting residents. LPA conducted interviews of Staff #1 (S1) and Licensee, reviewed Medical discharge documents during this visit. LPA observed the areas where resident #1 fell: once in the bedroom and another on the backyard patio. Licensee did not report any incidents to Community Care Licensing (CCL). LPA observed that S1 received 10 hours of initial training on how to care for residents on 8/18/22 which included aging process, physical limitation and special needs, bathing, grooming, feeding, toileting, and universal precautions, resident rights, Medication, Suspected abuse and abuse reporting. S1 demonstrated to LPA how R1 was handled during the return from the hospital on or about 2/22/24.
See 9099C for continuation...

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20240305091118

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: TENDER HOME SENIOR CARE	FACILITY NUMBER: 347003936
	VISIT DATE: 03/07/2024

NARRATIVE

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9099 Continued...

Based on the interviews, admittance and demonstration provided the allegations are deemed substantiated.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Licensee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20240305091118

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: TENDER HOME SENIOR CARE	FACILITY NUMBER: 347003936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/08/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Licensee shall submit a plan by fax to train staff on residents rights by POC due date of 3/8/24. In addition, submit a letter by fax indicating the in-service training for staff has been completed by 3/15/24.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on S1 did not allow R1 to sit rather than lie on bed. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 03/08/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from...humiliation...or other actions of a punitive nature...	1 2 3 4 5 6 7	Licensee shall submit a plan by fax to train staff on abuse by POC due date of 3/8/24. In addition, submit a letter by fax indicating the in-service training for staff has been completed by 3/15/24.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on R1 was demanded to lie down by S1. This violation poses an immediate health, and safety risk to residents in care.	8 9 10 11 12 13 14

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024

LIC9099 (FAS) - (06/04)

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