347004702-3-28-2022-27-AS-KHOS-CDGLJX-20220414084841

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004702
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:28:35 PM

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
01/20/2022 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20220120163656

FACILITY NAME:	MEADOWS AT COUNTRY PLACE, THE		FACILITY NUMBER:	347004702
ADMINISTRATOR:	GURSHAHBAZ SINGH		FACILITY TYPE:	740
ADDRESS:	10 COUNTRY PLACE		TELEPHONE:	(916) 706-3949
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	34	CENSUS: 23	DATE:	03/28/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Junelle Pangilinan		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff did not following COVID protocols.
Illegal eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Victoria Brown arrived unannounced on a subsequent visit on 3/28/22 at 10am. This visit is to conclude the investigation of the above mentioned allegations. LPA met with Rangi Giner, Administrator and Junelle Pangilinan, medication Technician and Beatriz Diwata, Medication Technician and stated the purpose of today’s visit.

Regarding allegation,"Facility staff did not follow COVID protocols", the investigation revealed that the Administrator was aware of the requirement to continue care for residents with Covid that is stated in the Provider Information Notices (PIN) PIN 21-38-ASC, PIN 21-49-ASC, and PIN 21-50-ASC.
The Administrator did not allow R1 to return home once discharged from the hospital due to covid diagnosis and continually going to public places without wearing a mask.

Substantiated

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: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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-20220120163656

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: MEADOWS AT COUNTRY PLACE, THE	FACILITY NUMBER: 347004702
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/29/2022 Section Cited CCR 87468.2(a)(6)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities In addition to the rights listed in Section 87468.1...personal rights:To make choices concerning their daily lives in the facility.	1 2 3 4 5 6 7	The current Administrator/Licensee shall submit in writing that all residents personal rights will be upheld at all times. An inservice to be conducted with staff by 4/12/22. To be faxed by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Administrator/License did not ensure R1 was allowed personal rights option of wearing a mask. Based on previous Administrator confirming resident was not allowed to return to facility due to going to public places not wearing a mask. This possess an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type A 03/29/2022 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	Eviction The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5).	1 2 3 4 5 6 7	The current Administrator/Licensee shall submit in writing that all residents when deemed necessary be given an eviction notice with pertinent information included in the notice as per Health and Safety Code and Title 22 Regulations. To be faxed by POC due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Administrator/License did not ensure R1 was allowed to return when discharged from the hospital. Based on previous Administrator confirming resident was not allowed to return to facility due covid diagnosis and was sent to family home. This possess 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: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20220120163656

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: MEADOWS AT COUNTRY PLACE, THE	FACILITY NUMBER: 347004702
	VISIT DATE: 03/28/2022

NARRATIVE

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Regarding allegation,"Illegal eviction" LPA observed that on the Incident report submitted to Community Care Licensing (CCL) on 1/17/22 it indicated that Resident #1 (R1) was sent to the hospital on 1/15/22 for possible fever and shortness of breath. Administrator Gurshahbaz Singh wrote that due to covid diagnosis and frequent visits to public places not wearing a mask during covid-19, resident was taken home by family to quarantine. In addition, Administrator submitted follow-up documentation to CCL regarding the allegations which also stated that R1's doctor was made aware that R1 was not able to be cared for at the facility with the current condition at which time R1 was then discharged to the family. On the same document it states that on 1/23/22, the Administrator had a conference with the family reiterating that R1 had to be cared for in a medical setting even if the hospital states otherwise.

Although, the Administrator stated there was no eviction mentioned, the administrator did not allow R1 to return to the facility once discharged from the hospital.

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 Staff 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 the report was given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC9099 (FAS) - (06/04)

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