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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700256
Report Date: 07/24/2023
Date Signed: 07/24/2023 04:00:00 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, 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
07/18/2023 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20230718111955
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:
07/24/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Melba PicardoTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff did not provide proper accommodations to client in care
INVESTIGATION FINDINGS:
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On 7-24-23 1:15pm, Licensing Program Analysts (LPAs) Michael Bilger and Arvin Villanueva arrived unannounced to open and investigate the complaint allegation noted above. LPAs met with staff member Melba Picardo and explained the purpose of the visit. During this investigation, LPAs interviewed staff1 (S1) at facility and Administrator via telephone. LPAs also interviewed resident1 (R1) via telephone. Additionally, LPAs reviewed individualized program plan (IPP) admission agreement, and work schedule for R1. Based on record review and interviews conducted during this investigation, it was determined that R1 sustained a work schedule which allowed R1 days off. It was revealed that R1 expressed wishes to reside at facility during R1's days off but was denied by facility staff due to staff unable to accommodate supervision for R1 during these days and times, resulting in R1 having to reside at another location.

Based on this investigation, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citations are issued and noted on the LIC 9099D. An exit interview was conducted with Melba Picardo and a copy of this report was left with Melba. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
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 2
Control Number 27-AS-20230718111955
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: H AND R HOME CARE FACILITY #2
FACILITY NUMBER: 392700256
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
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 to submit a staffing plan which ensures accommodation for all residents who wish to reside at facility up to 24 hours per day. Plan to be submitted to LPA by POC due date.
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Licensee did not ensure R1's personal rights in that R1 was denied access to facility during R1's days off from work, which posed a potential health, safety, and resident rights risk to residents in care.
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Licensee and staff to complete training on resident rights. Proof of completed training to be sent to LPA by POC due date.
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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: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2