347004461-12-7-2022-27-AS-SRIN-CMASEK-20221220124852

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004461
Report Date: 12/07/2022
Date Signed: 12/07/2022 10:56:21 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, 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
10/19/2022 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20221019133417

FACILITY NAME:	GREENSTAR RCFE		FACILITY NUMBER:	347004461
ADMINISTRATOR:	DAVID M. HOUSTON		FACILITY TYPE:	740
ADDRESS:	962 GREENSTAR WAY		TELEPHONE:	(916) 400-4656
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 6	DATE:	12/07/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jeanne Bayan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff sexually abused a resident while in care
Staff attempted to steal a resident's personal belonging
Staff caused injuries to a resident while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/7/22 at 10:30am to conclude the investigation and deliver the complaint findings. LPA met with Jeanne Bayan, Caregiver who contacted Angeline Kang, Administrator and stated the purpose of the visit.

Regarding allegations, “Staff sexually abused a resident while in care, Staff attempted to steal a resident's personal belongings, Staff caused injuries to a resident while in care”, Community Care Licensing (CCL) conducted interviews and reviewed medical records and police report.
The interviews and records revealed that Resident #1 (R1) has self-harm behaviors and reported that staff #1 (S1) sexually assaulted leaving bruises, attempted rape, was rough with activities of daily living (ADL)’s, pushed and knocked R1 to the ground, stole a crystal necklace, attempted to steal blood and a bag of urine. R1 was taken to be seen by a physician and is in the beginning stages of Dementia. R1’s responsible party (RP) is comfortable with R1 returning to the facility and commends the care R1 has been receiving at the home.

Unfounded

Estimated Days of Completion: 60

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

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-20221019133417

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: GREENSTAR RCFE	FACILITY NUMBER: 347004461
	VISIT DATE: 12/07/2022

NARRATIVE

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There was no evidence of sexual assault, based on the medical records.
A review of R1's Physician Report (LIC602) dated 9/26/22 indicated a diagnosis of Delirium, Urinary Tract Infection (UTI), Major Neurocognitive disorder due to another medical condition w/behavioral disturbance, and Mild Cognitive Impairment (MCI). The Client/Resident Personal Property and Valuables (LIC 621) form was not completed by R1 or RP upon admission which was confirmed by the responsible party. There was insufficient evidence to substantiate the allegation(s).

Based on interviews and observation of documentation, the preponderance of evidence standards has not been met; therefore, the above allegation(s) is found to be UNFOUNDED.

“This agency has investigated the complaint alleging, the above-mentioned allegation(s). We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were cited during this visit. 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: 12/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2022

LIC9099 (FAS) - (06/04)

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