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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 03/08/2023
Date Signed: 03/08/2023 10:34:13 AM

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
12/21/2022 and conducted by Evaluator Avelina Martinez
COMPLAINT CONTROL NUMBER: 27-AS-20221221143954
FACILITY NAME:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR:SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
03/08/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH: Ermelinda SiebenthalTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Wrongful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/08/2023 at 9:00 am to deliver complaint findings, LPA Martinez met with Ermelinda Siebenthal and explained the purpose of the visit.

Throughout the course of the investigation, LPA conducted interviews and reviewed facility files and documentation. It was learned resident 1 (R1) was admitted into the hospital, and at the time discharge R1 was not accepted back at the facility. In addition, the facility did not provide R1 a 30-day eviction letter and or notice, as a result, the facility did not follow eviction procedures.

Due to this investigation, the Department finds the allegation to be 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 the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
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, 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
12/21/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221221143954

FACILITY NAME:SIEBENTHAL CARE HOMEFACILITY NUMBER:
347004958
ADMINISTRATOR:SIEBENTHAL, ERMELINDAFACILITY TYPE:
740
ADDRESS:7948 HUNTS RUN WAYTELEPHONE:
(916) 689-3595
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
03/08/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH: Ermelinda SiebenthalTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not ensure that resident attended their medical appointments as necessary.
Staff did not seek medical attention for resident in a timely manner.
Staff are not responding to requests for communication regarding resident.
Staff did not ensure that resident took their medications as prescribed by their physician.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 03/08/2023 at 9:00 am to deliver complaint findings, LPA Martinez met with Ermelinda Siebenthal and explained the purpose of the visit.

Throughout the course of this investigation, LPA conducted interviews, reviewed records/files. Based on records/files, facility staff was in communication with resident 1's (R1) responsible parties (RP). It was noted facility staff requested R1's RP to schedule medical appointments. In addition, it was noted R1 refused to attend medical appointments. Therefore, there is not a preponderance of evidence to prove facility staff did not ensure R1 was attending their medical appointments or seeking medical attention in a timely manner.

Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
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 27-AS-20221221143954
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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
VISIT DATE: 03/08/2023
NARRATIVE
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Moreover, staff informed RP that R1 was being sent out to the hospital via Ambulance services. It was learned R1's assigned hospital was not accepting patients at the time of transport, and R1 was re-routed to another hospital. Staff 1 (S1) reported they did not make the decision to re-route R1 to another hospital. As a result, their is not a preponderance of evidence to prove S1 sent R1 to another unassigned hospital.

Furthermore, facility documentation reports communication was being held between facility staff and RP. Also, there was no other communication documentation between medical staff and S1. Due to the lack of documentation, there is not a preponderance evidence to prove S1 was not responding to medical staff or RP. Additionally, the facility maintained a medication administration record (MAR) for prescribed and As needed medication (PRN). The MARs reported R1 received their medication. It was also, learned S1 did not have access to R1's medication refill online portal, and facility records show S1 requested RP to refill medication; there is not a preponderance of evidence to prove staff did not ensure that R1 took their medications as prescribed.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of this report was given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20221221143954
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: SIEBENTHAL CARE HOME
FACILITY NUMBER: 347004958
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2023
Section Cited
CCR
87224(a)
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87224(a) Eviction Procedures: 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...This requirement was not met as evidence by:
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Licensee agrees to: review eviction regulations by POC date 03/20/2023. LPA a written statement stating eviction regulations have been reviewed by POC date 03/20/2023
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based on file review and interviews, the Licensee did not ensure to provide R1 or their responsible party a 30-day eviction letter and/or notice. This posed a potential health and safety risk to R1.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4