347004196-3-30-2022-25-AS-KHOS-CDEJEX-20220412065949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004196
Report Date: 03/30/2022
Date Signed: 03/30/2022 09:57:07 AM

Unfounded

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
01/05/2022 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20220105145658

FACILITY NAME:	IN LOVING HANDS CARE HOME II		FACILITY NUMBER:	347004196
ADMINISTRATOR:	FLORICA SFERDIAN		FACILITY TYPE:	740
ADDRESS:	7710 CHIPMUNK WAY		TELEPHONE:	(916) 792-7664
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 5	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Florica Sferdian, Administrator		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Facility is retaining a resident beyond their level of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open allegations listed above. LPA met with Administrator Florica Sferdian 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 Personal Protective Equipment (PPE) was worn.
LPA investigated the allegation, “Facility is retaining a resident beyond their level of care”. R1 moved into the facility in August 2021. R1’s LIC602 dated 12/14/2021 states resident “has chronic left medial ankle wound”. LPA reviewed R1’s medical documents which shows R1 was being treated from September 2021 for cellulitis by a podiatrist. Medical documents indicate follow up appointments with podiatrist occurred however wound care referral was not needed.
Continuation on 9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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 4

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
01/05/2022 and conducted by Evaluator Bethany Mirlohi

COMPLAINT CONTROL NUMBER: 25-AS-20220105145658

FACILITY NAME:	IN LOVING HANDS CARE HOME II		FACILITY NUMBER:	347004196
ADMINISTRATOR:	FLORICA SFERDIAN		FACILITY TYPE:	740
ADDRESS:	7710 CHIPMUNK WAY		TELEPHONE:	(916) 792-7664
CITY:	CITRUS HEIGHTS	STATE: CA	ZIP CODE:	95610
CAPACITY:	6	CENSUS: 5	DATE:	03/30/2022
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Florica Sferdian, Administrator		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Resident sustained an injury in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Bethany Mirlohi arrived unannounced to open allegations listed above. LPA met with Administrator Florica Sferdian 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 Personal Protective Equipment (PPE) was worn.
LPA investigated the allegation, “Resident sustained an injury in care”. R1 moved into the facility in August 2021. R1’s LIC602 dated 12/14/2021 states resident “has chronic left medial ankle wound”. LPA reviewed R1’s medical documents which shows R1 was being treated from September 2021 for cellulitis by a podiatrist. Medical documents indicate follow up appointments with podiatrist occurred however wound care referral was not needed.
Continuation on 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20220105145658

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
	VISIT DATE: 03/30/2022

NARRATIVE

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In November 2021 R1 was sent out to the emergency department due to a change of condition and was diagnosed with a stroke. Upon admission to the hospital resident was noted to have left ankle cellulitis. R1 remained in the hospital and then a skilled nursing facility (SNF) until returning to the facility on 12/21/21. LPA reviewed discharge paperwork from SNF which documented several skin conditions on R1 upon being discharged. R1 was sent out to the emergency department again on 1/4/22 due to change in condition. LPA reviewed hospital documentation, and there was no documentation indicating resident had an injury. Relevant Party indicates on 1/5/22 a bedsore was discovered. LPA spoke to a Homehealth representative, in which they stated R1 did not have a stageable wound and the skin tear was healing. Due to the information gathered LPA finds allegation to be UNSUBSTANTIATED.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20220105145658

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
	VISIT DATE: 03/30/2022

NARRATIVE

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In November 2021 R1 was sent out to the emergency department due to a change of condition and was diagnosed with a stroke. Upon admission to the hospital resident was noted to have left ankle cellulitis. R1 remained in the hospital and then a skilled nursing facility (SNF) until returning to the facility on 12/21/21. LPA reviewed discharge paperwork from SNF which documented several skin conditions on R1 upon being discharged. Skin conditions documented are not a prohibited health care condition. LPA spoke to R1’s homehealth in which they stated client did not have a prohibited healthcare condition. R1 was sent out to the emergency department again on 1/4/22 due to change in condition. LPA reviewed hospital documentation, and there was no documentation indicating resident had a prohibited healthcare condition. LPA interviewed R1 in which they stated they feel facility staff are caring for them properly and indicated they have had skin issues on and off for many years. Due to the information gathered LPA finds allegation to be Unfounded.

A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Bethany Mirlohi	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2022

LIC9099 (FAS) - (06/04)

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