392700332-3-23-2021-27-AS-KHOS-BZFJBS-20210325065450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700332
Report Date: 03/23/2021
Date Signed: 03/23/2021 11:20:46 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
01/29/2021 and conducted by Evaluator Ashley Boothe

COMPLAINT CONTROL NUMBER: 27-AS-20210129140721

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:	03/23/2021
		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 left resident in soiled diaper for extended period of time
Staff not meeting residents care needs

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 left resident in soiled diaper for extended period of time and staff not meeting residents care needs. 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 conducted interviews. Resident one (R1's) records were not available for LPA to review from the facility or Power of Attorney (POA). R1 was at the facility for two weeks time and referred to Hospice and moved to another licesned facility. Licensee stated the facility census included 6 hospice residents and a hospice waiver request was not submitted to the Department. POA stated R1's primary diagnosis stroke R1 was able to communicate needs to staff but it was hard to understand R1. Staff one (S1) stated R1 was taken care of well, all needs met and R1 received Home Health services multiple times per week.

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 2

Control Number 27-AS-20210129140721

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: 03/23/2021

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.

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: 03/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2