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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004196
Report Date: 01/11/2022
Date Signed: 01/11/2022 03:08:44 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
12/28/2021 and conducted by Evaluator Bethany Mirlohi
COMPLAINT CONTROL NUMBER: 25-AS-20211228150217
FACILITY NAME:IN LOVING HANDS CARE HOME IIFACILITY NUMBER:
347004196
ADMINISTRATOR:FLORICA SFERDIANFACILITY TYPE:
740
ADDRESS:7710 CHIPMUNK WAYTELEPHONE:
(916) 792-7664
CITY:CITRUS HEIGHTSSTATE: CAZIP CODE:
95610
CAPACITY:6CENSUS: 5DATE:
01/11/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Florica Sferdian, Administrator TIME COMPLETED:
03:20 PM
ALLEGATION(S):
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Staff is appointed as resident's power of attorney
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to continue investigation into allegation listed above. LPA met with Administrator, Florica Sferdian and Adina Sbingu, during today's inspection. LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Masks.
LPA conducted interviews and obtained resident documentation. LPA obtained R1's Advanced Health Care Directive, in which it states a staff member is one of R1's Durable Power of Attorney for Health Care. LPA interviewed Administrator in which she stated staff member is one of R1's Durable Power of Attorney for Health Care. As a result of this investigation, LPA finds allegations to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
Deficiencies cited on 9099-D. Exit interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
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 2
Control Number 25-AS-20211228150217
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: IN LOVING HANDS CARE HOME II
FACILITY NUMBER: 347004196
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/28/2022
Section Cited
CCR
87217(d)(2)
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87217 Safeguards for Resident Cash, Personal Property, and Valuables. (d) Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:(2) accept any general or special power of attorney for any such person;
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Administrator and staff have begun the process of dissolving the POA agreement and R1 will have another individual outside of the facility as medical POA. Administrator agrees to send
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This requirement is not met as evidenced by: Based on record review the licensee staff had Medical POA for R1 which poses a potential health and safety risk to resident's in care.
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new medical POA paperwork by 1/28/22.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany MirlohiTELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
LIC9099 (FAS) - (06/04)
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