392700473-12-24-2021-27-AS-KHOS-CA5LZ2-20211228081111

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700473
Report Date: 12/17/2021
Date Signed: 12/24/2021 02:41:37 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
06/07/2021 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210607111649

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:	DATE:	12/17/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sheryl Bravo		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff do not respond to resident pendants in a timely manner.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 12/17/2021 by LPA Charlie Yang. This LPA was met by the facility designated Administrator Sheryl Bravo who was briefly interviewed.
Current census was 50 residents of which 10 were from the memory care unit.
The purpose of this visit was to present the findings of this complaint investigation to this facility and its representative at this time.
A review of the resident pendant/alarm system implemented throughout this facility was conducted. Documents were requested dating back to the beginning of this year 2021 specifying when resident pendants were activated and the amount of time it took for facility staff to respond and clear the event.
Based on a review of the data compiled since the beginning of 2021 for response times from facility staff to resident alerts, there were alerts/events that were addressed in under one minute to other alerts/events that went over 30 minutes in duration before a staff member was able to address the needs of the residents and clear the event.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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 5

Control Number 27-AS-20210607111649

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: 12/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 12/24/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements-General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on a review of the data compiled since the beginning of 2021 for response times from facility staff to resident alerts,	1 2 3 4 5 6 7	Facility representative stated that a refresher course will be offered, for no less than (1) hour in duration, on the topic of responding to resident call buttons requesting assistance, in a timely manner. The trainer, topic covered, and attendees will be documented and submitted into CCL by the due date.
	8 9 10 11 12 13 14	there were alerts/events that were addressed in under one minute to other alerts/events that went over 30 minutes in duration before a staff member was able to address the needs of the residents and clear the event. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.	8 9 10 11 12 13 14
	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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
06/07/2021 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210607111649

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:	DATE:	12/17/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sheryl Bravo		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff are not changing residents who are incontinent.

Residents are not getting their showers that are agreed to in the care plan.

Staff person threatened a resident.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 12/17/2021 by LPA Charlie Yang. This LPA was met by the facility designated Administrator Sheryl Bravo who was briefly interviewed.
Current census was 50 residents of which 10 were from the memory care unit.
The purpose of this visit was to present the findings of this complaint investigation to this facility and its representative at this time.
Based on a review of the resident records, it was learned that there was a total of 27 residents who were dependent on the facility staff to assist with showers as noted on their care plans. In addition, there were 13 residents who were deemed to be incontinent of bowel/bladder requiring some form of assistance as well.
Based on interviews conducted with facility residents, it was learned that facility staff were very responsive to the care plans and followed them as outlined. Based on interviews, facility residents who required assistance with toileting, changing, and cleaning after experiencing incontinence issues were fairly satisfied with the staff.
It was learned that shower schedules were followed on a weekly basis and that most showers took place after dinner right before bedtime. It was learned that PM caregivers were responsible for this task.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20210607111649

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
	VISIT DATE: 12/17/2021

NARRATIVE

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Based on a review of the facility incident reports dating back to January 2021, it was learned that there was a reported incident of a caregiver pushing a resident while in care. This resulted in an internal investigation being conducted with the eventual termination of the facility caregiver as the outcome. This particular incident took place in the Assisted Living portion of this facility and not in the Memory Care unit.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 27-AS-20210607111649

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
	VISIT DATE: 12/17/2021

NARRATIVE

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This facility was found to not be in compliance at this time since this posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.

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 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 given to the facility designated Administrator, Sheryl Bravo, at this time.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5