347005264-10-26-2020-27-AS-SDOB-BWXPWS-20210104104112

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005264
Report Date: 10/26/2020
Date Signed: 10/26/2020 04:28:26 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:	DATE:	10/26/2020
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Licensee Princess Johnson		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident assaulted another resident.

INVESTIGATION FINDINGS:

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Unannounced complaint visit (Call) via conference call on 10/26/20. LPA Lund spoke with Licensee, Princess Johnson and explained the reason for the call. The current census is 14 residents.

The purpose for the call is to deliver complaint findings to Licensee Princess Johnson regarding the allegations of “Resident assaulted another resident”.

During the course of the investigation, LPA conducted interviews with staff, witnesses and residents. A review was conducted on facility records, plan of operation and incident reports.

On November 2, 2019, the Department received an unusual incident report stating: On November 1, 2019, one staff member attempted to redirect R-1 who was trying to smoke a cigarette inside the facility. When asked to go to the designated area R1 became aggressive towards the staff and hit two residents’ but were not injured. Galt PD was called and R1 was taken into custody and has not returned back to the facility.

Substantiated

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: 04/22/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020

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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On September 17, 2019, the Department received an unusual incident report stating: On September 16, 2019, R2 came into the kitchen and began to yell at staff. Staff asked him to leave the kitchen and R2 grabbed a cooking pan and struck staff twice in the forearm. Staff was able to get R2 to drop the pan and returned to his room. Galt PD was called and R2 was taken into custody and has not returned back to the facility.

Based on this investigation, the plan of operation for the facility is to care for resident’s with dementia as the primary diagnosis. According to R1 and R2, both clients physician report indicates primary diagnosis of schizoaffective.

Based on a review of records and investigation (Plan of operation, LIC 602A’s, Galt PD police reports and letters from the Conservator Office) the facility Licensee Princess Johnson accepted R1 and R2 with the primary diagnosis of Schizoaffective and behavior issues. As a result of the inappropriate placement R1 and R2 assaulted staff and resident’s which endangered the health and safety of Dementia Resident’s in care.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

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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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/26/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/03/2020 Section Cited CCR 87468(a)(1)	1 2 3 4 5 6 7	87468(a)(1)-Personal Rights-Each resident shall have personal rights which include, but are not limited to, the following: To be accorded dignity in his/her personal relationships with staff, residents, and other persons. This requirement is met evidence by:	1 2 3 4 5 6 7	Licensee will look over the regulation and have a plan in action for future events at the facility.
	8 9 10 11 12 13 14	The Facility accepted two Residents with the primary diagnosis of Schizoaffective. The assaulted Staff and Resident’s and that is a threat to the health and safety of Dementia Resident’s in care. This poses and immediately safety risk to clients.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020

LIC9099 (FAS) - (06/04)

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