390317215-4-16-2021-27-AS-KHOS-C29PNL-20210420112806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 390317215
Report Date: 04/16/2021
Date Signed: 04/16/2021 03:58:44 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
12/03/2020 and conducted by Evaluator Ashley Boothe

COMPLAINT CONTROL NUMBER: 27-AS-20201203173825

FACILITY NAME:	GOLDEN ACRES HOME AND CARE		FACILITY NUMBER:	390317215
ADMINISTRATOR:	MARICEL YAPO		FACILITY TYPE:	740
ADDRESS:	1101 CALIFORNIA STREET		TELEPHONE:	(209) 838-3405
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	26	CENSUS: 25	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Marivic Teano-Chau		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility failed to assist resident with appropriate transportation.

INVESTIGATION FINDINGS:

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On 4/16/2021 at 4pm Licensing Program Analyst (LPA) Ashley Boothe contacted Licensee Marivic Teano-Chau and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegations: facility failed to assist resident with appropriate transportation. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 25.

During the investigation, LPA conducted interviews and reviewed records provided by Licensee including Resident one (R1)’s Physician's Report LIC 602, Incident report, Care Plan, Emergency Contact Sheet, and Local Law Enforcement Police Report.

Continued on 9099 C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

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

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
12/03/2020 and conducted by Evaluator Ashley Boothe

COMPLAINT CONTROL NUMBER: 27-AS-20201203173825

FACILITY NAME:	GOLDEN ACRES HOME AND CARE		FACILITY NUMBER:	390317215
ADMINISTRATOR:	MARICEL YAPO		FACILITY TYPE:	740
ADDRESS:	1101 CALIFORNIA STREET		TELEPHONE:	(209) 838-3405
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	26	CENSUS: 25	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Marivic Teano-Chau		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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9

Failure to report

INVESTIGATION FINDINGS:

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On 4/16/2021 at 2:20pm Licensing Program Analyst (LPA) Ashley Boothe contacted Licensee Marivic Teano-Chau and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegations: Failure to report. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 25.

During the investigation, LPA conducted interviews and reviewed records provided by Licensee including Resident one (R1)’s Physician's Report LIC 602, Incident report, Care Plan, Emergency Contact Sheet, and Local Law Enforcement Police Report.

Continued on 9099 C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20201203173825

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: GOLDEN ACRES HOME AND CARE	FACILITY NUMBER: 390317215
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/07/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency (1) A written report ....within seven days of the occurrence of (D )Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidence by:	1 2 3 4 5 6 7	The licensee agrees to submit a POC to LPA at ashley.boothe@dss.ca.gov by POC due date of 5/7/2021. The licensee emailied LPA a copy of the report. Licensee stated they have purchased updated fax machines.
	8 9 10 11 12 13 14	Based on records reviewed and interview the Licensee did not ensure the incident report for R1's threatening behavior was submitted timely. Licensee stated the machine used did not provide confirmation of transmission receipt to ensure it was sent within 7 days which poses a potential health and safety 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20201203173825

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: GOLDEN ACRES HOME AND CARE	FACILITY NUMBER: 390317215
	VISIT DATE: 04/16/2021

NARRATIVE

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Continued from 9099A.

Based on record review and interviews R1 engaged in an incident of behaviors including agitation and threatening harm to themselves and others while in the facility. Staff one (S1) contacted San Joaquin Behavioral Health Services Crisis hotline who based on the assessment of R1's behavior instructed S1 to request local law enforcement's assistance to provide R1 transportation to hospital for evaluation. R1 was provided emergency medical transportation to hospital by ambulance. LPA observed the record of the LIC624 was documented by Licensee the following day but here is no record of the report on file with the Regional Office. The Licensee stated it was faxed from their home fax machine which was old and did not provide confirmation of transmission receipt. LPA reviewed facility fax files and there are no incident reports for R1’s behaviors submitted to the RO recording incidents staff stated increased frequency after R1's medication change that fall under required reporting requirement to be submitted to the RO. The licensee emailed LPA LIC624 16 days after the incident occurred upon LPA request.

It was determined in the course of the investigation based on the information provided through documentation, the allegations of facility failure to report were substantiated meaning that there was a preponderance of evidence to prove that the allegations occurred as reported. The preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.
The following deficiencies were cited on 9099-D per Title 22, Division 6 of the California Code of Regulations.
Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted. A copy of this report was provided to via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 9099, LIC 9099-D and appeal rights were received. The Licensee is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20201203173825

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: GOLDEN ACRES HOME AND CARE	FACILITY NUMBER: 390317215
	VISIT DATE: 04/16/2021

NARRATIVE

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Continued from 9099.

Based on record review and interviews R1 engaged in an incident of behaviors including agitation and threatening harm to themselves and others while in the facility. Staff one (S1) contacted Behavioral Health Services Crisis who based on the assessment of R1's behavior instructed S1 to request local law enforcement's assistance to provide R1 transportation to hospital for evaluation. Interview with Crisis stated the standard operating procedure would be to recommend that emergency medical services are called transport for anyone who is agitated or threatening harm to themselves or others. When local law enforcement officers arrived, S1 was was observed calmed. Interviews stated R1's history of calming down upon emergency medical personnel arrival during episodes of behaviors. S1 again contacted Crisis and was advised to follow procedures in that R1 be provided transport to hospital by emergency services. R1 was provided transport for to hospital by ambulance. S1 stated there have been other instances where facility staff provided R1 transport when R1 was not threatening harm but requesting Crisis evaluation and they follow Crisis's recommendations for when to contact emergency services for resident transport to hospital evaluation.

It was determined in the course of the investigation based on the information provided through documentation and interview, the allegations of facility failed to assist resident with appropriate transportation are unfounded. This agency has investigated the complaint alleging facility failed to assist resident with appropriate transportation. We have found the allegations false.

No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the 9099 and appeal rights were received. The licensee is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5