<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700473
Report Date: 11/03/2020
Date Signed: 11/03/2020 04:37:57 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
05/20/2020 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200520105328
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:
03:15 PM
MET WITH:Cathy Otte, Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff arranged ride share for the transportation of a resident (R-1) during a mental health crisis.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
LPA Bruce Jacobs contacted Executive Director Cathy Otte by phone 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 medical records and the facility's records. Interviews with facility management, staff and other witnesses were conducted.

The complaint alleges that the facility staff had arranged for a ride share for the transportation for a resident (R-1) at a time the resident was having a mental health crisis. The resident was transported to a mental health crisis center by the ride share and left at the clinic. The resident did not immediately enter the facility was seen by clinic staff walking down the street, away from the clinic.

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)
Page: 1 of 2
Control Number 27-AS-20200520105328
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
12/03/2020
Section Cited
CCR
87646(f)(1)(C)
1
2
3
4
5
6
7
Basic Services: (f) Basic services shall at a minimum include: (1) Care & 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. Resident (R-1) was mentally unstable and observed to be having erratic behavior. Facility staff
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 observation of residents. Also, care staff are properly trained to perform their basic duties to meet the needs of the residents. LPA determined inadequate judgement was used in this situation.
8
9
10
11
12
13
14
arranged for the resident to be evaluated at a mental health clinic and staff arranged for the resident to be transported by a rideshare company and the resident was taken to the clinic and then left there. The resident did not immediately enter the clinic and was see walking down the street. This poses a potential health and safety risk to the resident.
8
9
10
11
12
13
14
 The facility staff who made this decision is not longer working at the facility. 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 by 12/03/20
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-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)
Page: 2 of 2