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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700256
Report Date: 06/04/2025
Date Signed: 06/04/2025 02:52:34 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
03/20/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250320120901
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:
06/04/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lourdes FernandezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is operating out of scope of license.
INVESTIGATION FINDINGS:
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On 6-4-2025 at 1:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Licensee Lourdes Fernandez and explained the purpose of the visit. During this investigation, LPA conducted interviews with two staff members and one client in care. Additionally, LPA reviewed facility file documentation including facility license, discharge paperwork for resident1 (R1), physician’s report for R1, care notes for R1, and physician orders for R1. LPA also conducted a facility observation on 4-30-25. Based on interviews and record reviews, it was revealed that R1 was discharged from a skilled nursing rehabilitation facility on or about 3-14-25 with physician orders for home health nursing, therapy, and use of walker. A review of facility license revealed facility may accept up to six ambulatory residents only.

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

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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 27-AS-20250320120901
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: 06/04/2025
NARRATIVE
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Based on definitions as stated in Health and Safety Code Community Care Regulations (CCR) Section 80001(n)(2): "Nonambulatory Person" means a person as defined in Health and Safety Code Section 13131. Health and Safety Code Section 13131 provides in part:"Nonambulatory persons" means persons unable to leave a building unassisted under emergency conditions. It includes any person who…depend upon mechanical aids such as crutches, walkers, and wheelchairs… An observation conducted on 4-30-25 revealed a walker place in R1’s room. Additional interviews conducted revealed R1 has and is using the walker as a need for proper mobilization assistance.

As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, division 6 and noted on LIC 9099D. An immediate civil penalty in the amount of five-hundred dollars ($500) is issued in addition to citation due to violation of CCR Section 80020(b)(2). An exit interview was conducted with Licensee and a copy of this report was provided. Appeal rights and LIC 811 provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20250320120901
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: 06/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/05/2025
Section Cited
CCR
80020(b)(2)
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80020 Fire Clearance (b) The applicant shall notify the licensing agency if the facility plans to admit any of the following categories of clients so that an appropriate fire clearance, approved by the city or county, fire department, the district providing fire protection services, or the State Fire Marshal, can be obtained prior to the acceptance of such clients: (2) Persons who are nonambulatory, as defined in Section 80001n.(1). This requirement was not met as evidenced by:
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Licensee has already sent appropriate paperwork to LPA for processing designated room for non-ambulatory use.

Licensee will read regulation 80020 and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review, interview, and observation, licensee did not ensure an appropriate fire clearance prior to accepting a non-ambulatory client. This posed an immediate health and safety risk to resident 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: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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
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
03/20/2025 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20250320120901

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:
06/04/2025
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Lourdes FernandezTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not ensure a Restricted Health Condition Care Plan was created for resident
INVESTIGATION FINDINGS:
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On 6-4-2025 at 1:00pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Licensee Lourdes Fernandez and explained the purpose of the visit. During this investigation, LPA conducted interviews with two staff members and one client in care. Additionally, LPA reviewed facility file documentation including facility license, discharge paperwork for resident1 (R1), physician’s report for R1, care notes for R1, medication log sheets for R1, and physician orders for R1. LPA also conducted a facility observation on 4-30-25. Based on interviews and record reviews, it was determined that R1 discharged from skilled nursing rehabilitation on or about 3-14-25 and sent back to H&R Home Care Facility #2. Medication logs reviewed upon discharge and current medication logs did not reveal insulin to be given to R1. A review of discharge paperwork from skilled nursing did not reveal insulin among the listed medications to be sent home with R1. An observation of R1’s medication on hand at facility on 4-30-25 did not reveal insulin present.

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

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
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 27-AS-20250320120901
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: 06/04/2025
NARRATIVE
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Based on interview, it was revealed that although R1 was sent home with insulin, facility staff did not administer insulin as no physician’s order existed instructing staff to do so. Interview conducted with R1 revealed he did not receive insulin after his return to facility. An interview with facility administrator and records review revealed that a physician’s order existed instructing insulin to not be given. As a result, facility administrator discarded and destroyed insulin.

Based on evidence presented, it is determined that a restrictive health condition care plan for insulin was not developed and submitted by licensee as facility did not and could not administer insulin due to a nonexistent order. As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Licensee and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5