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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700473
Report Date: 11/03/2020
Date Signed: 12/15/2020 12:58:53 PM



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
09/10/2020 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200910072857
FACILITY NAME:MANTECA RTRMT COM-HAPPY LVNG BY COGIR/COGIR MANTECFACILITY NUMBER:
392700473
ADMINISTRATOR:CATHERINE OTTEFACILITY TYPE:
740
ADDRESS:430 NORTH UNION RDTELEPHONE:
(209) 823-0164
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:84CENSUS: 53DATE:
11/03/2020
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Cathy Otte, Executive DirectorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility caregiver slapped a resident on the face and grabbed the resident causing injuries
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. The investigation was conducted by LPA Jacobs and consisted of reviews of the facility's records. Interviews with facility management, staff, resident(s) and other witnesses were conducted.

The complaint alleges that the facility caregiver (S-1) slapped a resident and forcefully grabbed the resident causing injuries. Based on all interviews as well as photo evidence, Licensing has concluded that the caregiver (S-1) slapped, grabbed and charged at a dementia resident (R-1) when the resident was agitated in the memory care unit. Injuries were noted on the resident's arm after the caregiver forcefully grabbed the resident.

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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (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)
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Control Number 27-AS-20200910072857
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 A
11/11/2020
Section Cited
CCR
87468.1(a)(3)
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Personal Rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...

This requirement was not met as evidenced b
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Plan of correction: The facility has terminated the staff named in the report. The facility will provide in-service training to all caregivers on the residents' personal rights, dementia related behaviors and the appropriate response to the behaviors.
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The care giver (S-1) in the memory care area forcefully grabbed, slapped and charged at the resident (R-1) when the resident was agitated and was having dementia related behaviors. Photos taken of the resident document bruises on the resident's arm and direct witnesses corroborated the incident. This poses an immediate health risk to residents in care.
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Written POC due by the POC date with completion of the training to be completed with 30 days of this report and proof of training to be sent to CCL.
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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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Bruce JacobsTELEPHONE: (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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