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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700256
Report Date: 10/08/2024
Date Signed: 10/08/2024 03:32:59 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240830150730
FACILITY NAME:H AND R HOME CARE FACILITY #2FACILITY NUMBER:
392700256
ADMINISTRATOR:FERNANDEZ, LOURDES CFACILITY TYPE:
735
ADDRESS:928 DEWITT COURTTELEPHONE:
(209) 547-1961
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 6DATE:
10/08/2024
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Lourdes FernandezTIME COMPLETED:
03:32 PM
ALLEGATION(S):
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Staff denies a client access to the home
Staff forces a client to attend a day program
Staff takes the clients to their personal residence
INVESTIGATION FINDINGS:
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On 10/8/2024 at 1:45pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to deliver and discuss findings for the complaint allegations noted above. LPA met with Administrator Lourdes Fernandez and explained the purpose of the visit. During this investigation LPA conducted interviews with four residents in care and Administrator. LPA also conducted facility file review of physician’s report, individualized program plan (IPP), staffing schedule, and facility’s program design. Additionally, documentation from a witness statement regarding this complaint was also reviewed as part of this investigation.

Allegation: Staff denies a client access to the home. LPA conducted interviews and record reviews as stated above. Based on interviews and record reviews conducted, it was revealed that resident1 (R1) has expressed at various times a desire to remain at home in lieu of attending day program.

{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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-20240830150730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: H AND R HOME CARE FACILITY #2
FACILITY NUMBER: 392700256
VISIT DATE: 10/08/2024
NARRATIVE
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Furthermore, it was revealed through interviews that R1 was told on various occasions by facility staff that R1 could not stay at the facility due to the temporary unavailability of staff while all other residents were attending day program. A review of R1’s IPP and physician’s report indicates R1 can make own decisions. A review of facility established rights as noted in facility’s program design section “Residents’ Rights and Responsibilities” state: “You have the right to…Treat the facility as your home and to regard yourself as a member of a facility consisting of other residents and staff.” As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff forces a client to attend a day program. LPA conducted interviews and record reviews as stated above. Based on interviews and record reviews conducted, it was revealed that R1 has expressed at various times a desire to remain at home in lieu of attending day program. Furthermore, it was revealed through interviews that R1 was told on various occasions by facility staff that R1 had to attend day program due to temporary unavailability of staff while all other residents were out of facility and attending day program. A review of R1’s IPP and physician’s report indicates R1 can make own decisions. A review of facility established rights as noted in facility’s program design section “Residents’ Rights and Responsibilities” state: “You have the right to…Socialize with whomever and whenever you choose.” As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation: Staff takes the clients to their personal residence. LPA conducted interviews and record reviews as noted above. Based on these interviews and record reviews it was revealed that on various occasions Administrator took residents to a private residence for activities which included watching movies. Additionally, it was revealed through interviews that residents were at a private residence for excessive hours. It was further revealed through record review and interviews that although staff were present during the times residents were at a private residence, This private residence is not included in facility’s program design or approved by regional center as a chosen venue for activities or other care and supervision needs at any time or for any reason, which resulted in a potential hazardous environment for residents in care. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citations are issued under Title 22, Division 6 and noted on LIC 9099D. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240830150730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: H AND R HOME CARE FACILITY #2
FACILITY NUMBER: 392700256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
CCR
80072(a)(2)
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Personal Rights. (a) …each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment to meet his/her needs. This requirement was not met as evidenced by:
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Licensee will submit a plan ensuring the allowance of residents to access the facility at all times. Plan to be submitted to LPA by POC due date.

Licensee will read regulation 80072(a)(2) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interviews and record review, Licensee did not ensure comfortable accommodations for R1 as requested. This posed a potential health, safety, and resident rights risk to resident in care.
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Type B
10/21/2024
Section Cited
CCR
80072(a)(1)
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Personal Rights. (a) …each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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Licensee will ensure completed staff training on resident rights and submit proof of completed training to LPA by POC due date.
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Based on interviews and record reviews, Licensee did not ensure R1’s preference for remaining at facility in lieu of attending a social day program. This posed a potential health, safety, and resident rights risk to resident in care.
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Licensee will submit a plan to ensure residents who choose to stay home in lieu of a social day program will be able to do so. Plan to include staffing measures as necessary to meet resident needs.

Licensee to read regulation 80072 (a)(1) and submit a signed declaration of understanding to LPA by POC due date.
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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20240830150730
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: H AND R HOME CARE FACILITY #2
FACILITY NUMBER: 392700256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
CCR
80064(a)(2)
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Administrator - Qualifications and Duties. (a) The administrator shall have the following qualifications: (2) Knowledge of the requirements for providing the type of care and supervision needed by clients…This requirement was not met as evidenced by:
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Licensee to read regulation 80064 and submit a signed declaration of understanding to LPA by POC due date.
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Based on interviews and record reviews, Administrator did not provide an appropriate and approved venue for residents’ care and supervision needs in that Administrator took residents to Administrator’s private residence for activities. This posed 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: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4