<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005570
Report Date: 07/27/2022
Date Signed: 07/27/2022 02:08:15 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, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20220413112225
FACILITY NAME:CLARA CARE HOMEFACILITY NUMBER:
347005570
ADMINISTRATOR:KIM, JAE YOELFACILITY TYPE:
740
ADDRESS:4665 FREEWAY CIRCLETELEPHONE:
(916) 900-4781
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 6DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Okki Kim, Acting AdministratorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unqualified staff are dispensing medication

Administrator is not at the facility for the required time
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Acting Administrator, Okki Kim, to deliver findings into the allegations listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises.

During today’s visit, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Unqualified staff are dispensing medication

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
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 5
Control Number 25-AS-20220413112225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
VISIT DATE: 07/27/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Interview with Administrator and Acting Administrator conducted on 4/21/2022 indicated that facility staff are administering injections to resident (R1) using "hand-over-hand" method. Administrator and Acting Administrator mimed method in which staff push down R1's thumb on injection to help administer medication.

Interview with staff member (S1) conducted on 4/21/2022 indicated that S1 did not feel well trained enough to help with medication administration for R1, particularly injections.

Interview with Acting Administrator conducted on 7/27/2022 indicated that facility stopped using "hand-over-hand" method when administering injections for R1 after LPA's visit on 4/21/2022. Facility now supervises R1 when self-administering injections.

Allegation: Administrator is not at the facility for the required time

Interview with Acting Administrator indicated that Administrator, Jae Yoel Kim, has not been at the facility since May 2022. Acting Administrator stated that they are at the facility twice a week for a time period that varies.

Administrator and Acting Administrator were not at the facility at the time LPA arrived unannounced during inspections conducted on 4/21/2022 and 7/27/2022.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with Acting Administrator. A copy of this report and appeal rights were provided. Acting Administrator's signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20220413112225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2022
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. (…) This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility ceased "hand-over-hand" method of helping resident (R1) with injections after 4/21/2022 inspection. Facility will conduct a staff training on medication administration. Administrator will submit date of training and training material to LPA by POC due date of 7/28/2022.
8
9
10
11
12
13
14
Based on interviews conducted, the facility did not ensure that residents needing injections were self-administering medication, which poses an immediate health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
08/11/2022
Section Cited
CCR
87405(a)
1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Facility will assign Acting Administrator as Administrator. New Administrator will submit to LPA a weekly schedule indicating the times and days in which Administrator is working at the facility. Administrator will submit schedule to LPA by POC due date of 8/11/2022
8
9
10
11
12
13
14
Based on interviews conducted and observation, the facility did not ensure that Administrator is at the facility for a sufficient amount of time, which poses a potential health, safety, and personal rights risk to residents in care.
8
9
10
11
12
13
14
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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20220413112225

FACILITY NAME:CLARA CARE HOMEFACILITY NUMBER:
347005570
ADMINISTRATOR:KIM, JAE YOELFACILITY TYPE:
740
ADDRESS:4665 FREEWAY CIRCLETELEPHONE:
(916) 900-4781
CITY:SACRAMENTOSTATE: CAZIP CODE:
95841
CAPACITY:6CENSUS: 6DATE:
07/27/2022
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Okki Kim, Acting AdministratorTIME COMPLETED:
02:25 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is retaining a resident who has a higher level of care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Acting Administrator, Okki Kim, to deliver findings into the allegation listed above. LPA wore an N-95 mask. Facility staff wore masks while on the premises.

During today’s visit, LPA conducted interviews and requested documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility is retaining a resident who has a higher level of care

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20220413112225
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
VISIT DATE: 07/27/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During inspection conducted on 7/27/2022, LPA review resident files for residents R1, R2, R3, R4, R5, R6, and R7. During file review, LPA did not observe any prohibited health conditions with any of the residents receiving care, or previously receiving care, at the facility.

During inspection conducted on 7/27/2022, LPA toured the facility and did not observe any residents with prohibited health conditions.

Based on observation and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is 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.

Exit interview was conducted with Administrator and a copy of this report was provided to the facility. The signature of the Administrator on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: 916-531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5