347004958-12-11-2024-27-AS-KHOS-DBZPQA-20241216103050

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:30:15 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2024 and conducted by Evaluator Kevin Gould

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240719112743

FACILITY NAME:	SIEBENTHAL CARE HOME		FACILITY NUMBER:	347004958
ADMINISTRATOR:	SIEBENTHAL, ERMELINDA		FACILITY TYPE:	740
ADDRESS:	7948 HUNTS RUN WAY		TELEPHONE:	(916) 689-3595
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 5	DATE:	12/11/2024
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ermelinda Siebenthal		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1) Staff yells at the residents.
2) Staff threatens the residents
3) staff hit a resident.
4) staff tie doors closed to prevent residents from leaving bedrooms.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Siebenthal Care Home RCFE on 12/11/24 at 1:00pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with Licensee, Ermelinda Siebenthal and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould conducted interviews with four staff members (see confidential name list LIC-811 dated 12/11/24) Who all denied the above allegations. No staff interviewed witnessed any staff member yell at, threaten, or hit residents in care. LPA contacted the authorized representatives for all residents. LPA was able to conduct phone interviews with two of the five authorized representatives and both denied any concerns regarding the allegations and provided statements they are satisfied with the care their family receives. Report continued on LIC 9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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 27-AS-20240719112743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIEBENTHAL CARE HOME	FACILITY NUMBER: 347004958
	VISIT DATE: 12/11/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA attempted to interview all residents, only two residents were able to provide statements to LPA as all residents in care have a diagnosis of dementia. The two residents interviewed expressed to LPA they are happy in the home and treated with kindness and respect. The two residents interviewed denied being hit, yelled at or threatened by any staff member.

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 (indicate the complaint allegation) are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

LPA conducted a walk through of the facility on multiple occasions and at different times and did not observe any devices, equipment, ropes or other items that could be used to secure bedrooms and lock residents in their bedrooms. No staff member was able to corroborate the allegation and provided statements they have never witnessed the bedroom doors being locked or secured by other means.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2