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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003936
Report Date: 08/26/2022
Date Signed: 08/26/2022 11:42:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2022 and conducted by Evaluator Kevin Gould
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220624114911
FACILITY NAME:TENDER HOME SENIOR CAREFACILITY NUMBER:
347003936
ADMINISTRATOR:MARINOVA, VALENTINAFACILITY TYPE:
740
ADDRESS:3499 PONZI COURTTELEPHONE:
(916) 851-1888
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 3DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Valentina MarinovaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Qualifications:
1) staff did not received appropriate medication training as required
2) staff lacked the ability to effectively communicate with residents as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Tender Home Senior Care RCFE on 8/26/22 at 10:00am to conclude the investigation of the above allegations and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, and observations made by LPA the allegations have been corroborated. LPA reviewed staff training files for staff member assigned to administer medications in the Licensee's absence. LPA observed that wile the staff member did have the required annual training hours, the licensee could not produce an examination that tested the medication administration skills as required by regulations. The licensee was unaware of the requirement as it was part of the health and safety code and not part of the Title 22 regulations.

Report continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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 5
Control Number 27-AS-20220624114911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936
VISIT DATE: 08/26/2022
NARRATIVE
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LPA observed that during an inspection on 6/29/22, when LPA arrived at the facility, a staff member was present alone at the facility who was unable to communicate effectively with residents and potentially emergency responders in the case of an emergency. Although the staff member was alone with residents for a short time, an emergency can take place at any moment and there must be a staff member present who can communicate with residents and emergency responders at all times.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of qualifications is substantiated but if any additional information is received this complaint can be amended and the finding can be changed.

The following deficiencies are cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20220624114911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2022
Section Cited
HSC
1569.69(a)(5)
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To complete the training requirements set forth in this subdivision, each employee shall pass an examination that tests the employee’s comprehension of, and competency in, the subjects listed in paragraph (4). This requirement was not met as evidenced by LPA review of staff file which and statements from the licensee that the staff member did not
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Licensee will provide a written statement to LPA that the Licensee understand the requirement and to identify all staff that will be administering medications to residents in the future and provide LPA with a sample examination that meets the requirements in the Health and Safety code.
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complete an examination regarding medication administration and was not aware of the requirement which poses a potential health, safety and personal rights risk to residents in care.
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Type B
09/02/2022
Section Cited
CCR
87411(d)(3)
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Personnel Requirements - General: Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by observations by LPA who observed a staff member alone at the facility who could not speak english and would not be able to
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Licensee will provide a written statement that they understand that the staff member cannot be at the facility alone with residents due to their inability to communicate effectively with residents. Licensee will provide LPA and update LIC 500 which shows a new staff shedule that include an addidtional staff member whenever a staff present is unable to communicate with residents.
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communicate effectively with residents to meet their needs and communicate with emergency responders in the case of an emergency at the facilty which poses a potential health, safety and personal rights risk to residents in care. The department emphasizes that we are not prohibiting non-english speakers from working in a licensed facility, but one staff member must be present who can effectively communicate with residents to meet their needs at all times a resident is present in the facility.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/24/2022 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20220624114911

FACILITY NAME:TENDER HOME SENIOR CAREFACILITY NUMBER:
347003936
ADMINISTRATOR:MARINOVA, VALENTINAFACILITY TYPE:
740
ADDRESS:3499 PONZI COURTTELEPHONE:
(916) 851-1888
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 3DATE:
08/26/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Valentina MarinovaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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other: the administrator was not of good character when she was observed working at the facility drunk.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Tender Home Senior Care RCFE on 8/26/22 at 10:00am to conclude the investigation of the above allegation and to deliver the findings. LPA met with Licensee and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because no resident or resident family member could corroborate the allegations. LPA Gould conducted interviews with two staff members and three family members of residents and none of the interviewed residents or family could corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.
Report continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
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 5
Control Number 27-AS-20220624114911
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: TENDER HOME SENIOR CARE
FACILITY NUMBER: 347003936
VISIT DATE: 08/26/2022
NARRATIVE
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There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5