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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005345
Report Date: 01/24/2022
Date Signed: 01/24/2022 03:01:16 PM

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
12/23/2021 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20211223095815
FACILITY NAME:PEER HOME 2FACILITY NUMBER:
347005345
ADMINISTRATOR:ANTONIO "TANYA" BERNADASFACILITY TYPE:
735
ADDRESS:7727 MASTERS STREETTELEPHONE:
(916) 509-9450
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:4CENSUS: 4DATE:
01/24/2022
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Raul CupinoTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff are not following current COVID-19 masking requirements
Facility staff are not observing COVID-19 physical distancing guidance
Residents are posted on social media without consent
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived at the facility unannounced to deliver complaint investigation findings. LPA Valerio was screened for COVID-19 symptoms with temperature taken prior to being allowed entry. Administrator confirmed that residents or staff have not displayed any signs or symptoms of COVID-19 in the last 10 days. LPA Valerio observed staff wearing masks upon arrival.

Complaint investigation consisted of interview with staff and document review. The department has determined the following as it relates to the above mentioned allegations.

On 12/23/21, the department received screenshots of social media postings from Staff 1 and Staff 2. Screenshots revealed that licensed facilities, Cupino Home and Peer Home #2, were having a holiday party at the care homes. 7 out of 8 screenshots were of Peer Home #2.

Continued on LIC 809 - C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
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
Control Number 27-AS-20211223095815
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: PEER HOME 2
FACILITY NUMBER: 347005345
VISIT DATE: 01/24/2022
NARRATIVE
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...Continued from LIC 9099

Staff and residents were observed to be unmasked and sitting or standing within 6 feet distance. Staff and residents did not appear to be eating or drinking during the times video footage was recorded and when pictures were being taken. Facility staff were not following current COVID-19 guidelines.

LPA Valerio reviewed facility files. LPA observed 0 consent forms in the resident files. Residents and/or their responsible parties must sign a consent form prior to any photography or video recording. The facility did not ensure to obtain consent prior to posting on Facebook, a social media platform. The licensee was unaware of the social media post and informed staff to remove the post immediately.

Administrator confirmed that there was a holiday party; however, there has not been anyone sick since the party. Administrator also stated that everyone that came to the party was screened prior to entering. Administrator stated staff always wear mask and follow all procedures.

Based on observation, interview, and facility file review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC-9099D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided.  An exit interview was conducted, and a copy of the report was provided to Administrator Raul Cupino.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20211223095815
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: PEER HOME 2
FACILITY NUMBER: 347005345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly...2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by:
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The licensee stated they will continue to follow all COVID-19 mask, vaccination, booster, and visitation requirements. LPA reviewed policies and updated mitigation plan with licensee during visit. Licensee to review regulations with staff and inform LPA Valerio when completed by POC due date.
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The licensee did not ensure to protect the personal rights of clients in care to receive safe and healthful accommodations, in that facility staff failed to wear face coverings while providing care and supervision to clients in care This poses a potential health and safety risk to residents in care.
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Type B
02/24/2022
Section Cited
CCR
87307(d)(3)(B)
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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:(3)All persons shall be protected... (B)...regarding life protection and other appropriate subjects. This requirement was not met as evidenced by:
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The licensee stated they will continue to follow all COVID-19 mask, vaccination, booster, and visitation requirements. LPA reviewed policies and updated mitigation plan with licensee during visit. The licensee will discuss and review policies with staff by POC due date.
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The licensee did not ensure clients in care to be protected against hazards within the facility, in that 2 facility staff were inside the facility not practicing social distancing, which is a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20211223095815
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: PEER HOME 2
FACILITY NUMBER: 347005345
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/24/2022
Section Cited
CCR
87568.2(a)(1)
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87468.2 Additional Personal Rights of Residents...(a)...shall have all of the following personal rights:(1) To have a reasonable level of personal privacy...This requirment was not met as evidenced by:
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The licensee stated the staff that posted the photos and video on social media will delete the post by COB 01/24/2022. The licensee will review policies with staff and inform LPA once it has been completed. The licensee will ensure to obtain consent forms if any photo or video is taken in the future.
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The licensee did not ensure to maintain personal privacy of 4 out of 4 residents in care by requiring staff to obtain consent prior to staff posting pictures of the residents on a social media platform. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4