347005570-7-27-2022-25-AS-KHOS-CK3PLK-20221010112452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347005570
Report Date: 07/27/2022
Date Signed: 07/27/2022 01:03:24 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
07/26/2022 and conducted by Evaluator Michael Hood

COMPLAINT CONTROL NUMBER: 25-AS-20220726142625

FACILITY NAME:	CLARA CARE HOME		FACILITY NUMBER:	347005570
ADMINISTRATOR:	KIM, JAE YOEL		FACILITY TYPE:	740
ADDRESS:	4665 FREEWAY CIRCLE		TELEPHONE:	(916) 900-4781
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95841
CAPACITY:	6	CENSUS: 6	DATE:	07/27/2022
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Okki Kim, Acting Administrator		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Staff do not properly supervise residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Acting Administrator, Okki Kim, to open a complaint investigation 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: Staff do not properly supervise residents

** Report continued on 9099-C **

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 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)

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Control Number 25-AS-20220726142625

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

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Interview conducted with Acting Administrator indicated that the facility has one (1) live-in staff member (S1) who sleeps at the facility at night but is on-call to assist residents with care throughout the night. LPA observed a time sheet for S1 indicating that S1 works 4 days a week from 8:00 AM to 4:30 PM. On days in which S1 is not working, staff member (S2) works from 7:00 AM to 7:00 PM. There is no time-sheets for Administrators.

LPA reviewed resident records for residents R1, R2, R3, R4, R5, R6, and R7. Physician's Report (LIC 602) for R2 with a physician's signature dated 4/28/2022 indicates that R2 has a diagnosis of dementia. Preplacement Appraisal Information (LIC 603) for R2 dated 4/29/2017 indicates that R2 has "Alzheimer's dementia" and needs special observation/night supervision. Resident Appraisal (LIC 603A) for R2 dated 12/18/2018 indicates that R2 has "Alzheimer's Dementia" and needs special observation/night supervision due to confusion, forgetfulness, and wandering. Resident Appraisal (LIC 603A) for R2 dated 4/15/2022 indicates that R2 is "confused and disoriented, unable to communicate due to Dementia," and indicates both "yes" and "no" to R2 needing special observation/night supervision.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is 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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 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)

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Control Number 25-AS-20220726142625

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 B 10/14/2022 Section Cited CCR 87705(c)(4)(A)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility will complete a statement of understanding regarding regulation 87415. Facility will submit statement of understanding to LPA by POC due date of 10/14/2022.
	8 9 10 11 12 13 14	Based on interviews conducted and records reviewed, the facility did not ensure that R2, who has a dementia diagnosis, had awake night supervision, which poses an potential health, safety, and personal rights risk to residents in care.	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: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael Hood	TELEPHONE: 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)

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