347005264-10-26-2020-27-AS-SDOB-BWXPWT-20210104104113

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005264
Report Date: 10/26/2020
Date Signed: 10/26/2020 04:21:00 PM

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
01/10/2020 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20200110135551

FACILITY NAME:	STAINLESS RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	347005264
ADMINISTRATOR:	JUSTICE O EHIMAMIEGHO		FACILITY TYPE:	740
ADDRESS:	407 MAPLE STREET		TELEPHONE:	(916) 821-2391
CITY:	GALT	STATE: CA	ZIP CODE:	95632
CAPACITY:	18	CENSUS: 14	DATE:	10/26/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee Prince Johnson		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Inadequate supevision led to resident being injured
Facility did not report incidents as required

INVESTIGATION FINDINGS:

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Unannounced complaint visit (Call) via conference call on 04/23/2020. LPA Lund talked to Licensee, Princess Johnson and explained the reason for the call.
Current census was 14 residents.
The purpose of this complaint visit was to complete the investigation and present the findings to the Licensee Princess Johnson.

Based on Interviews, review of records, plan of operation, Unusual Incident/Injury Reports (UIR-LIC 624), Resident (R-1) LIC 602 and Galt Police Department reports. April 8, 2019 County of Sacramento Senior and Adults Services notified Administrator Princess Johnson by letter prior to R-1 admittance to the facility. The letter stated that R-1 is conserved thru the county and has a history of Physical Assaults and Inappropriate Sexual Behaviors ”Impulsive” grabbing of others.

On April 8, 2020 Administrator signed the admission agreement for R-1. On November 2, 2019 the facility wrote a (UIR): R-1 hit one Resident but was not injured and got aggressive towards staff. R-1 was taken into custody by Galt PD and returned on a later date. Resident (R-1) has not had a history of incidents at the Facility and it was an isolated incident. The staffing at the time of the incident was two (2) staff to fourteen (14) Residents.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2020

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-20200110135551

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: STAINLESS RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 347005264
	VISIT DATE: 10/26/2020

NARRATIVE

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Based on Interviews, review of records, Unusual Incident/Injury Reports (UIR-LIC 624). When LPA Lund requested two (UIR’s) dated November 2, 2019 and September 17, 2019 from the Licensee Princess Johnson regarding Residents (R-1 & R-2) incidents Licensee Princess Johnson produced the UIR’s. LPA Lund checked the Electronic Facility Files and the UIR’s were not in the file. R-1 and R-2 are conserved by Sacramento County and confirmed that were aware of the incidents.

As a result of this investigation, this Department finds the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
There were no deficiencies observed or cited at this time.

The appeal rights were printed, and emailed to the Facility Administrator signed the copy and email copy back.

LPA Jason Lund Amended the complaint for signature on 11/5/20.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

LIC9099 (FAS) - (06/04)

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