392700557-12-6-2022-27-AS-KHOS-CLWKY2-20221208071824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700557
Report Date: 11/21/2022
Date Signed: 12/06/2022 03:50:05 PM

Substantiated

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
06/07/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220607151224

FACILITY NAME:	GELZHEN GUEST HOME LLC		FACILITY NUMBER:	392700557
ADMINISTRATOR:	LAJA, JOY		FACILITY TYPE:	740
ADDRESS:	119 N LINCOLN AVE		TELEPHONE:	(209) 239-5500
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	15	CENSUS: 7	DATE:	11/21/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Floyd Laja		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff handles resident in a rough manner

INVESTIGATION FINDINGS:

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Unannounced Complaint visit made out to this facility on 11/21/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Nichol Carbonell, who was briefly interviewed. This LPA requested that the facility caregiver go ahead and contact the Licensee/Facility designated Administrator to let him/her know that CCL was present at this time.
Current census was 7 residents.
Facility Licensee, Floyd Laja, arrived later to this facility while this LPA was conducting this visit.
The purpose of this visit was to deliver the findings of this investigation to the facility and its representative, Floyd Laja, at this time.
Based on interviews conducted during this investigative process, it was learned that there was an eyewitness account of how facility staff person, S1, roughly handled facility resident, R1, during assistance with R1 for Activities of Daily Living (ADL). It was learned that S1 abruptly threw R1 onto the bed after attempting to transfer R1. It was learned that from this action, R1's face became buried in R1's pillow and required further assistance to turn away from it by the facility staff person.

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: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

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-20220607151224

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: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
	VISIT DATE: 11/21/2022

NARRATIVE

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It was learned that R1 required assistance with transferring in/out of bed and to/from R1's wheelchair, toilet, and living room furniture. It was learned that R1 was deemed to be bedridden and required assistance with transferring, toileting, and required to be turned/pivoted on set intervals throughout the day and night.
Based on interviews, it was learned that staff person, S1, had dumped R1 onto R1's bed on several occasions and often times would cause the resident to roll. This caused R1 to roll towards the wall that was adjacent to R1's bed. It was learned that R1 would hit his head from this action by S1. No visible injuries were ever recorded or reported to CCL but happened more than once as stated in the interviews.

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 a copy was given to the facility Licensee, Floyd Laja, 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: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220607151224

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: GELZHEN GUEST HOME LLC	FACILITY NUMBER: 392700557
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/28/2022 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (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, such as withholding residents' money or interfering with daily living functions	1 2 3 4 5 6 7	Facility representative stated that staffing will be sufficient and competent at all times for adequate care and supervision unto all facility residents. A statement of correction, along with facility wide training for all staff providing care and supervision to the residents will be conducted. This training will be for no less than (2) hours in duration on the topic of resident
	8 9 10 11 12 13 14	such as eating, sleeping, or elimination. This facility was found to be deficient as evidenced by the violation of the resident's rights by facility staff while assisting and performing ADLs. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.	8 9 10 11 12 13 14	rights, resident dignity/respect, and proper transfer techniques. Proof of training will be submitted to include name of trainer, length of training with topics covered, and list of attendees by the due date of 11/28/2022.
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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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022

LIC9099 (FAS) - (06/04)

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