392700473-11-4-2020-27-AS-KHOS-BV8LC9-20201110073754

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700473
Report Date: 11/03/2020
Date Signed: 11/04/2020 10:40:21 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
03/16/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200316142014

FACILITY NAME:	MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC		FACILITY NUMBER:	392700473
ADMINISTRATOR:	CATHERINE OTTE		FACILITY TYPE:	740
ADDRESS:	430 NORTH UNION RD		TELEPHONE:	(209) 823-0164
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	84	CENSUS: 53	DATE:	11/03/2020
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Catherine Otte, Executive Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff neglected resident in care.

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs contacted Executive Director Cathy Otte by phone to complete this complaint investigation and deliver findings regarding the allegation listed above. LPA discussed the investigation and findings via email. The investigation was conducted by LPA Jacobs and consisted of reviews of medical records and the facility's records. Interviews with facility management, staff and other witnesses were conducted.

The complaint alleges that facility staff neglected a resident (R-1) in care. The investigation concluded that the resident (R-1) moved into his own room in the facility on 02/20/20. The resident had access to another room in the facility belonging to his father and was sleeping in that room as his bed had not yet arrived. Facility staff did not know the location of the resident for two days until he was located by a family member who came to the facility on 02/22/20. The resident did not receive his medications for two days, did not have his oxygen connected and was in need of changing when found.

Licensing has determined the above allegation is (S) 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 deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Exit interview conducted and report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

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 3

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
03/16/2020 and conducted by Evaluator Bruce Jacobs

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200316142014

FACILITY NAME:	MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC		FACILITY NUMBER:	392700473
ADMINISTRATOR:	CATHERINE OTTE		FACILITY TYPE:	740
ADDRESS:	430 NORTH UNION RD		TELEPHONE:	(209) 823-0164
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	84	CENSUS: 53	DATE:	11/03/2020
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Catherine Otte, Executive Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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9

Facility overcharged resident(s) in care.

Resident sustained injury while in care as a result of abuse or neglect.

INVESTIGATION FINDINGS:

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LPA Bruce Jacobs contacted Executive Director Catherine Otte and discussed the investigation and findings. The investigation was conducted by LPA Jacobs and consisted of reviews of medical records and the facility's records. Interviews with facility management, staff and other witnesses were contacted.

The complaint alleges that the facility overcharged residents (R-1,2) while in care. The allegation specified that resident (R-1) was charged for his time in the facility while he was in the hospital. Also, resident (R-2) was charged for the two days he was in the facility before he moved out. Per the facility and the Responsible Party, the facility did refund this time period for R-2. The facility also issued a prorated refund for R-1 until the time his belongings were removed from the facility. The complainant agreed the refund they received was accurate. Resident R-2 did sustain an injury at the facility when he fell out of his bed and the injury was not determined to be due to abuse or neglect.

Licensing has investigated the above allegations and determined the allegations are UNSUBSTANTIATED
Exit interview conducted and report provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

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 3

Control Number 27-AS-20200316142014

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: MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTEC	FACILITY NUMBER: 392700473
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/03/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/11/2020 Section Cited CCR 87646(f)(3)	1 2 3 4 5 6 7	Basic Services: (f) Basic services shall at a minimum include: (1) Care & supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). "Care and supervision" means the facility... provides ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.	1 2 3 4 5 6 7	Plan of Correction: Facility Administrator will develop a plan and conduct staff training to ensure staff is sufficiently trained on the resident's care and the supervision and observation of residents. Also, care staff are properly trained to perform their basic duties to meet the needs of the residents.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Resident (R-1) was accepted into the facility on 02/20/20 and given his own room. The resident had access to another room and was staying in that room. Staff did not know the resident's whereabouts for 2 days causing the resident to miss his medications, not have his oxygen and in need of incontinence care posing a potential health risk to the resident.	8 9 10 11 12 13 14	A written Plan of Correction detailing how the facility will implement an adequate procedure to observe and meet the resident's need. POC due by 11/11/20 and completion of training due within 30 days.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce Jacobs	TELEPHONE: (916) 956-5861
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2020

LIC9099 (FAS) - (06/04)

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