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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347005570
Report Date: 06/08/2023
Date Signed: 06/08/2023 04:33:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
08/05/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20220805075858
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:
06/08/2023
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Okki Kim, AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility staff are not following residents' dietary restrictions
Facility is not providing transportation for residents' medical appointments
Facility issued an unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Okki Kim, to to deliver findings regarding the complaint allegations listed above.

During the investigation, LPA conducted interviews and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility staff are not following residents' dietary restrictions

** 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: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
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 9
Control Number 25-AS-20220805075858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
VISIT DATE: 06/08/2023
NARRATIVE
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Interviews with relevant parties, staff members S1 and S2, and Administrator indicated that R1 would open the facility’s refrigerator at night and eat items that may not fit with R1’s special diet.

A review of R1’s documentation indicated the following dietary restrictions: Physician’s Report for RFCE (LIC 602A) for R1 dated 7/22/2022 states R1 has a special diet “pureed,” LIC 602A for R1 dated 4/8/2022 states R1 has a special diet “chopped meats level 3, ground vegetables, fluid restriction, thick liquids,” LIC 602A for R1 dated 7/15/2020 states R1 has a special diet “renal diet, soft,” LIC 602A for R1 dated 5/21/2018 states R1 has a special diet “renal.”

30-day eviction notice for R1 sent to relevant party authored by Administrator states the following: “my caregivers are not professional dietitians. Although we try to keep in mind what constitutes a renal diet, posting on the board what foods are prohibited, it is difficult for them to keep track considering the multitude of tasks and dietary restrictions each individual has. We are more than open to your corrections and recommendations but I ask that you are a little more understanding of my caregivers and do not blame them for such mistakes. Due to [R1’s] condition, I believe that [R1] would benefit from being placed into a different facility that can provide [them] supervision for [their] breathing troubles and a dietitian to manage [their] dietary needs.” LPA reviewed R1’s Admission Agreement, which states the facility should provide basic services which include “food services, to include 3 nutritious meals daily and snacks, special diets if prescribed by a doctor.”

Interview with Administrator indicated that there are currently no residents at the facility that have dietary restrictions. Interview with S1 indicated that R1 is the only resident who had dietary restrictions. S1 stated that R1 would help themselves to food items in the refrigerator all the time. S1 wanted to lock the food and facility was able to obtain a doctor's order on 7/14/2022 to lock food away from R1. However, R1 was already declining by the time that doctor's order for R1 was obtained. S1 stated that R1 broke into the refrigerator until doctor's order was obtained. S1 stated that R1's behavior of helping themselves to food items in the refrigerator stopped after obtaining doctor's order.

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

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 9
Control Number 25-AS-20220805075858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
VISIT DATE: 06/08/2023
NARRATIVE
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Allegation: Facility is not providing transportation for residents' medical appointments

Administrator stated that Anthem with Blue Cross was responsible for providing transportation to R1's medical appointments. Administrator stated that Anthem was not operating properly during COVID-19 pandemic and Licensee had to drive R1 to dialysis appointments, but Licensee could not personally drive R1 to all of their appointments. R1's family wanted facility to arrange an Uber ride for R1. Administrator stated that an Uber driver drove R1 to the wrong location. Police were contacted but Uber driver came back and returned resident to facility. Administrator stated that they told R1's family that they need licensed transportation for R1 and if the family wanted R1 to take an Uber, then the family is responsible to arrange an Uber for R1. Administrator stated that they eventually were able to obtain a better transportation company with Blue Cross. Administrator stated that, if R1's transportation did not show up to the facility for their appointment, they would contact Blue Cross and assign a different company to transport the resident. Administrator stated that R1 would miss their window to receive dialysis if transportation did not show up to pick up resident. Administrator stated that R1 missed their appointment a couple times because of either no transportation or R1 refusing dialysis appointments.

LPA reviewed text messages sent to relevant party authored by Administrator indicating the following: “Our suggestion is to research for a skilled nursing facility that can accommodate [R1’s] special needs as well as transportation. There are many facility that have their own transportation such as small minivans and small buses. It seems that transportation will always be a problem. We cannot continue to have day after day of these frustrating issues that cannot be resolved.” LPA reviewed R1’s Admission Agreement, which states the facility should provide basic services that include “transportation – we provide transportation to meet health needs within a 10 mile radius at least 4 times per month.”

S1 stated that resident (R2) had been trying to go to the dentist during the summer of 2022 for over a three month period. S1 stated that R2 had not been able to get transportation to see the dentist and the Administrator and Licensee were not at the facility to assist. S1 stated that they were unable to assist with transportation as they were the only care staff at the facility when transportation was needed.

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

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 9
Control Number 25-AS-20220805075858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
VISIT DATE: 06/08/2023
NARRATIVE
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Allegation: Facility issued an unlawful eviction

During the investigation, LPA obtained a copy of a 30-day eviction notice for resident (R1) from Administrator and relevant party. Both copies of eviction notice were identical. LPA obtained and reviewed correspondence from Senior Care Solutions sent to relevant party to relocate R1. 30-day eviction notice for R1 sent to relevant party authored by Administrator states the following: “I am giving you a 30 days notice to move [R1] to a place that is appropriate to your standards.”

LPA observed that 30-day eviction notice issued to R1 was missing an effective date, resources available to assist in identifying alternative housing and care options, information about the resident’s right to file a complaint with community care licensing and State Ombudsman as well as contact information for both, and the following statement: "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing."

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 Administrator. A copy of this report and appeal rights were provided. 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: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 9
Control Number 25-AS-20220805075858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/09/2023
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 87464. Facility will submit statement of understanding to LPA by POC due date of 6/9/2023.
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Based on interviews conducted and records reviewed, the facility did not ensure that R1 was following special diet, which poses an immediate health, safety, and personal rights risk to residents in care.
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Type A
06/09/2023
Section Cited
CCR
87465(a)(2)
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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: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 87465. Facility will submit statement of understanding to LPA by POC due date of 6/9/2023.
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Based on interviews conducted and records reviewed, the facility did not ensure that R1 had transportation to all medical appointments, which poses an immediate health, safety, and personal rights 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 9
Control Number 25-AS-20220805075858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/23/2023
Section Cited
HSC
1569.683
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§1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the notice to quit shall include all of the following: (...) This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding Health & Safety Code §1569.683. Facility will submit statement of understanding to LPA by POC due date of 6/23/2023.
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Based on interviews conducted and records reviewed, the facility did not ensure to follow Health & Safety Code when issuing an eviction notice, which poses a potential health, safety, and personal rights 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.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
08/05/2022 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20220805075858

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:
06/08/2023
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Okki Kim, AdministratorTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Facility does not properly assist residents with oxygen
Facility staff does not provide incontinence care
Facility staff physically restrain residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Okki Kim, to deliver findings regarding the complaint allegations listed above.

During the investigation, LPA conducted interviews, toured the facility, and reviewed documentation pertinent to the investigation.

The results of the investigation are as follows:

Allegation: Facility does not properly assist residents with oxygen

** 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: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 9
Control Number 25-AS-20220805075858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
VISIT DATE: 06/08/2023
NARRATIVE
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Interview with relevant party indicated that Mercy Hospice representatives did not document any concerns regarding resident (R1’s) oxygen use at the facility. Interview indicated that Mercy Hospice staff arrived at the facility to provide care for R1 multiple times a day to ensure oxygen was used properly. Interview indicated that Mercy Hospice documented that, on 7/29/2022, R1 was experiencing low oxygen saturation but oxygen was on and working properly when hospice staff arrived at the facility. Interview indicated that R1 started oxygen via nasal canula on 7/25/2022. Interview indicated that canula can come off easily when residents using oxygen are uncomfortable.

LPA observed oxygen signs posted at the facility for residents using oxygen, including R1, R2, and R7.

Allegation: Facility staff does not provide incontinence care

Interview with staff member S2 and Administrator indicated that R1 could manage their own incontinence needs prior to being placed on hospice. Interviews with staff member S1, Administrator, Licensee, and relevant party indicated that staff attempted to provide incontinence care services to R1 while family was at the facility and family refused care staff to provide care to R1. Interview with relevant party indicated R1 was placed on hospice services on 7/21/2022 and that Mercy Hospice did not document any observations of R1 being soiled when hospice staff arrived at the facility to provide care to R1.

A review of R1’s documentation indicated the following incontinence needs: Preplacement Appraisal Information (LIC 603) dated 8/25/2018 indicated that R1 did not require assistance with toileting. Physician’s Report for RFCE (LIC 602A) for R1 dated 5/21/2018 states that R1 is able to care for own toileting needs. LIC 602A for R1 dated 4/08/2022, prior to going on hospice services, states R1 is able to care for own toileting needs. LIC 602A for R1 dated 7/22/2022, after going on hospice services, states R1 is unable to care for own toileting needs.

Interviews with residents R2, R3, R4, R5, and R6 indicated that their care needs are being met at the facility.

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

DATE: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 9
Control Number 25-AS-20220805075858
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: CLARA CARE HOME
FACILITY NUMBER: 347005570
VISIT DATE: 06/08/2023
NARRATIVE
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Allegation: Facility staff physically restrain residents in care

Interviews with staff members S1, S2, and Administrator indicated that they have never restrained a resident at the facility. Interviews with residents R2, R3, R4, R5, and R6 indicated that they never experienced being physically restrained at the facility. All interviews above indicated that they have never witnessed staff restrain a resident at the facility.

Based on interviews conducted, observations, 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. A copy of this report was provided. 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: 06/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2023
LIC9099 (FAS) - (06/04)
Page: 9 of 9