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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700298
Report Date: 04/12/2022
Date Signed: 04/12/2022 01:13:04 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
04/11/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220411122205
FACILITY NAME:DIZON VALLEY CARE HOMEFACILITY NUMBER:
392700298
ADMINISTRATOR:DIZON, LISSETFACILITY TYPE:
735
ADDRESS:2830 SAN ROCCO DRTELEPHONE:
(510) 435-7428
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:6CENSUS: 4DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Baldwin, MaryTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not prevent resident from falling
Staff did not seek timely medical treatment for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Albert Johsnon arrived unannounced to open the above allegation.

Allegation: Staff did not prevent resident from falling. Based on interviews conducted with Licensee and Staff, S2 was working with R1 when R1 fell. S2 was not cleared to work at the facility and the facility does not have any documentation that S2 has been trained to work with S1. S1 has an identified unsteady gait that is documented. S1 was not present when R1 fell. S2 is no longer working at the facility. S2 does not have a file with training information including orientation.

Continued>>.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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-20220411122205
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: DIZON VALLEY CARE HOME
FACILITY NUMBER: 392700298
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/13/2022
Section Cited
CCR
80075(a)
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Health Related Services. Each client shall receive necessary first aid and medical or dental services, including arrangement for and/or provision of transportation to the nearest available service.

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The facility shall comply with state regulations in meeting the medical needs of all clients. The facility shall develop a procedure to follow when staff observe that any resident is in need of a medical assessment from a medical professional to ensure that medical attention is provided in a timely manner.
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-R1 did not receive timely medical attention for approximately Nine hours after the incident.

***This posed an immediate health/safety risk***
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Additionally, licensee/administrator shall secure a comprehensive training program from an outside agency on the importance of strict adherence and compliance of the cited regulation. To clear first part of deficiency, licensee to submit to LPA documentation of scheduled training date within 24 hours. Licensee to submit proof of training completion to LPA within 7 days of completion.
Type A
04/13/2022
Section Cited
CCR
85065(b)
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85065 Personnel Requirements
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.
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Licensee will submit a staffing plan to ensure residents are not left unattended by staffing personnel.

Licensee will submit a staffing schedule ensuring adequate coverage to prevent lack of
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This requirement is not met as evidenced by lack of training information for S2 ,including orientation and criminal record clearance. This poses an immediate health and safety concern for residents in care.
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supervision of residents.
Licensee to submit above POCs by 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: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20220411122205
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: DIZON VALLEY CARE HOME
FACILITY NUMBER: 392700298
VISIT DATE: 04/12/2022
NARRATIVE
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Allegation: Staff did not seek timely medical treatment for resident. Based on records reviewed the facility did not seek medical treatment until a call was received by Staff at Valley Mountain Regional Center at 12:30pm. R1 was taken to Sutter Health ER. at 6:30pm and released at approximately 8:00pm. R1 had the fall at approximately 9:00am. R1 was not taken to be evaluated until approximately nine hours after the incident.

As a result of this investigation, LPA finds the allegations to be Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview with Administrator
Appeal Rights printed
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
04/11/2022 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20220411122205

FACILITY NAME:DIZON VALLEY CARE HOMEFACILITY NUMBER:
392700298
ADMINISTRATOR:DIZON, LISSETFACILITY TYPE:
735
ADDRESS:2830 SAN ROCCO DRTELEPHONE:
(510) 435-7428
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:6CENSUS: 4DATE:
04/12/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Baldwin, MaryTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff made inappropriate comments to resident.
INVESTIGATION FINDINGS:
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LPA continued the investigation on this attached 9099A.

Allegation: Staff made inappropriate comments to resident. Based on interviews conducted with ll staff denied hearing or saying anything related to the complaint. There is a report of hearing S2 saying inappropiate things to S1, but it cannot be collabrated.

It was unclear if the staff said inappropriate comments to S1. Therefore, the allegation was deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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 4