392700332-3-23-2021-27-AS-KHOS-BZFJFC-20210325070030

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700332
Report Date: 03/22/2021
Date Signed: 03/23/2021 11:33:49 AM

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
12/15/2020 and conducted by Evaluator Ashley Boothe

COMPLAINT CONTROL NUMBER: 27-AS-20201215152232

FACILITY NAME:	A PLACE CALLED HOME II		FACILITY NUMBER:	392700332
ADMINISTRATOR:	SIMONE A PIERRE JEROME		FACILITY TYPE:	740
ADDRESS:	25820 MAGNOLIA AVE		TELEPHONE:	(209) 986-3949
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	11	CENSUS: 6	DATE:	03/22/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lesley Pinola		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not safeguard resident's personal items

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/23/2021 at 11am Licensing Program Analyst (LPA) Ashley Boothe contacted Licensee Lesley Pinola and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegations: Staff did not safeguard resident's personal items. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 6.

During the investigation LPA reviewed records and conducted interviews. Resident one (R1's) admissision's agreement dated move in on 9/2021. R1's responsible party stated the admissions packet was picked up from the Licnesee and filled out at home, and returned to the Licensee. Personal Property and Valuables signed by R1's repsonsilbe party included TV, bath towels, boxers, T shirts, Polos, Pants,Cross, and Prayer Book. Staff one (S1) interview stated R1's personal property were packed up and secured on the front porch of the facility.

Continued on 9099 C. Page 1 of 2.

Unsubstantiated

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: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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 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
12/15/2020 and conducted by Evaluator Ashley Boothe

COMPLAINT CONTROL NUMBER: 27-AS-20201215152232

FACILITY NAME:	A PLACE CALLED HOME II		FACILITY NUMBER:	392700332
ADMINISTRATOR:	SIMONE A PIERRE JEROME		FACILITY TYPE:	740
ADDRESS:	25820 MAGNOLIA AVE		TELEPHONE:	(209) 986-3949
CITY:	ESCALON	STATE: CA	ZIP CODE:	95320
CAPACITY:	11	CENSUS: 6	DATE:	03/22/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Lesley Pinola		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not report a change in resident's health condition
Staff did not seek medical care for resident in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/22/2021 at 11am Licensing Program Analyst (LPA) Ashley Boothe contacted Licensee Lesley Pinola and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegations: staff did not report a change in resident's health condition and staff did not seek medical care for resident in a timely mannerA physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census XX.

During the investigation LPA reviewed records and conducted interviews. R1's primary diagnosis was diabetes and obseity. R1's responsible party stated R1 moved in the facility in September after a fall and broken ankle. R1 was receiving home health servies multiple times per week. On 11/18/2020 R1's responsible party was notified R1 change in condition by Staff one (S1) and emergency medical services were called to transport R1 to Kaiser. R1 was diagnosed with UTI, perscribed antibiotics, and returned to the facility the same day.

Continued on 9099 C. Page 1 of 2.

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: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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 4

Control Number 27-AS-20201215152232

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: A PLACE CALLED HOME II	FACILITY NUMBER: 392700332
	VISIT DATE: 03/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 9099. Page 2 of 2.

Staff two (S2) stated on Friday they observed swelling starting in R1's leg and notified R1's responsible party. On 11/30/2020 R1's responsible party was notified by telephone call of puss coming from R1's ankle. S2 contacted emergency medical services to transport R1 to hospital where R1 was admitted for further evaluation. R1 was discharged to a higher level of care on and did not return to the facility.

Based on information obtained the aforementioned allegations are UNFOUNDED. This agency has investigated the complaint alleging staff did not report a change in resident's health condition and
staff did not seek medical care for resident in a timely manner. We have found the allegation was false, could not have happened or is without reasonable basis.

There are no deficiencies being cited per Title 22 Regulations. Exit interview was conducted with Lesley. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 9099, 9099 C, and Appeal Rights were received. Lesley is to print out the report and fax signed copies 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: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20201215152232

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: A PLACE CALLED HOME II	FACILITY NUMBER: 392700332
	VISIT DATE: 03/22/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from 9099. Page 2 of 2.

R1's responsible party stated they arrived approximately 30 minutes after the agreed time and loaded up R1's belongings into a uhaul. R1's responsible party stated S1 allowed entry to the facility and R1's responsible party removed additional items including R1's red walker, bath chair, and 49er's cup. S1 stated R1 walked through the facility and secured R1's 49er's cup. Items observed on personal property log were not identified during interview as missing or not missing when R1's responsible party picked up R1's belongings.

Based on information obtained the aforementioned allegations are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

There are no deficiencies being cited per Title 22 Regulations. Exit interview was conducted with Lesley. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 9099, 9099 C, and Appeal Rights were received. Lesley is to print out the report and fax signed copies 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: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4