392700473-9-12-2023-27-AS-LKIG-CVSPNZ-20230918112844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700473
Report Date: 09/07/2023
Date Signed: 09/12/2023 05:23:42 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
06/15/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230615102440

FACILITY NAME:	MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC		FACILITY NUMBER:	392700473
ADMINISTRATOR:	SHERYL BRAVO		FACILITY TYPE:	740
ADDRESS:	430 NORTH UNION RD		TELEPHONE:	(209) 823-0164
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	84	CENSUS: 60	DATE:	09/07/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Analyn Madarang and Sheryl Bravo		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility does not have an adequate supply of toiletries

Facility does not have an adequate supply of cleaning supplies

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 09/07/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the Health and Wellness Director, Analynn Madarang, who was briefly interviewed at this time. This LPA requested that the facility staff call and notify the facility designated Administrator, Sheryl Bravo, to inform her that CCL was present at this time. The facility designated Administrator, Sheryl Bravo, arrived shortly thereafter to this facility while this LPA was conducting this complaint visit.
Current census was 60 residents.
The purpose of this visit was to relay the information related to the findings of this complaint investigation to the facility designated Administrator, and staff, at this time.
Based on interviews and information gathered during the course of this investigation, it was learned that this facility experienced a shortage in cleaning supplies and toiletries during the month of May 2023 leading into June 2023. It was learned that the average orders from this facility usually ranged from 7-10 orders being placed per month. This was true for the months of March 2023 and April 2023 where the number of orders

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230615102440

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC	FACILITY NUMBER: 392700473
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 09/14/2023 Section Cited CCR 87307(a)(3)(D)	1 2 3 4 5 6 7	Living accommodations and grounds shall be related to the facility's function. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident Hygiene items of general use such as soap	1 2 3 4 5 6 7	The facility designated Administrator stated that hygiene products and toiletries for the residents will be sufficient and made available for use to the residents at all times. A statement of correction, along with copies of the facility toiletries and hygiene products orders list for the next (3) months, will be
	8 9 10 11 12 13 14	and toilet paper. This facility was found to deficient as evidenced by not having the required supplies of toiletries for use by the residents at all times. This posed an immediate threat to the Health, Safety and Personal Rights of the residents in care.	8 9 10 11 12 13 14	completed and submitted into CCL by the due date. A copy of the orders list will be submitted by the end of each month.
Deficiency Dismissed Type A 09/14/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This facility was found to be deficient as evidenced by not having the required	1 2 3 4 5 6 7	The facility designated Administrator stated that the facility cleaning supplies will be sufficient and made available for use by the facility staff at all times. A statement of correction, along with copies of the facility cleaning supplies and products orders list for the next (3) months, will be completed and
	8 9 10 11 12 13 14	supplies of cleaning supplies and products made available for use by the facility staff at all times. This posed an immediate threat to the Health, Safety and Personal Rights of the residents in care.	8 9 10 11 12 13 14	submitted into CCL by the due date. A copy of the orders list will be submitted by the end of each month.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230615102440

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC	FACILITY NUMBER: 392700473
	VISIT DATE: 09/07/2023

NARRATIVE

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placed throughout these months were around ten.
It was learned that the number of orders placed dropped drastically to only 5 for the month of May 2023 and the same number of orders placed, 5, for the month of June 2023.
In addition, it was also learned that the last order for toiletries and cleaning supplies was last placed on 05/24/2023. The next order for supplies was not placed until 06/19/2023 for a period of almost a month later.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

LIC9099 (FAS) - (06/04)

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