347004958-12-12-2023-27-AS-CACL-CYQN3Y-20231221090708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347004958
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:55:15 PM

Substantiated

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
12/08/2023 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20231208140918

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:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ermelinda Siebenthal		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to the residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility to commence a complaint investigation with the allegation above. LPA met with Administrator Ermerlinda Siebenthal and explained the purpose of the visit.

Based on the interviews conducted and reviewed of records, it was learned that on 12/8/23 resident (R1) and (R2) AWOL'd out of the side gate of the facility without staff knowledge. It was learned that R1 and R2 Physician’s Report prohibited resident from leaving the facility unsupervised due to Dementia diagnosis. The administrator corroborated that she noticed the residents were not on the facility premises and proceed to search the neighborhood. R1 and R2 were found without any visible injuries and bought the residents back to the facility. It was determined that due to lack of supervision, resident R1 and R2 left the facility unsupervised on 12/8/2023.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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-20231208140918

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: 12/12/2023

NARRATIVE

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As a result of this investigation, LPA finds the allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. CIVIL PENALTIES ARE ASSESSED IN THE AMOUNT OF $500 today for immediate violations.

Exit interview conducted, a copy of this report, LIC 9099-D, and appeal rights were provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20231208140918

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/13/2023 Section Cited HSC 1569.312(d)	1 2 3 4 5 6 7	Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services:...(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. A statement of correction will be submitted by plan of correction date of 12/13/2023 via email to LPA Tung Truong. Proof of staff training for the cited section will be completed and a signature sheet of all staff who attended will be submitted to LPA after training is finished.
	8 9 10 11 12 13 14	Based on interviews and record review, the facility did not comply with section cited above in 1569.312(d). R1 and R2 AWOL'D from facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This poses an immediate health and safety risk to the resident in care.	8 9 10 11 12 13 14	Immediate civil penalty of $500.00 is assessed for health and safety deficiency.
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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-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC9099 (FAS) - (06/04)

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