392700603-3-29-2022-27-AS-SDOB-CD7QXZ-20220405123423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700603
Report Date: 03/28/2022
Date Signed: 03/29/2022 05:43:45 PM

Unsubstantiated

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
11/16/2021 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20211116150852

FACILITY NAME:	AUSTIN ROAD HOME		FACILITY NUMBER:	392700603
ADMINISTRATOR:	WARREN, KATHY		FACILITY TYPE:	735
ADDRESS:	16590 S AUSTIN RD		TELEPHONE:	(209) 823-6061
CITY:	MANTECA	STATE: CA	ZIP CODE:	95336
CAPACITY:	6	CENSUS: 4	DATE:	03/28/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Michelle Ayala and Melinda Womble		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility staff are not providing a safe environment for clients in care

Facility did not seek timely medical attention for client.

Resident sustained injury while in care.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 03/28/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver Michelle Ayala. This LPA requested that she go ahead and contact the facility designated Administrator to inform her that CCL was present at this time. The facility designated Administrator, Melinda Womble, arrived shortly thereafter to this facility.
Current census was 4 residents.
Based on a review of the forms and documents that were provided by this facility, it was learned that R1 has a long history of being unsteady with their balance and gait. As a result there have been reported falls and injuries sustained from these incidents. This facility did properly report and submit the required information into CCL for each event involving R1. There were a total of (2) reported incidents for R1 dating back to 09/2021 for fall related events and injuries. It was learned that medical attention was always sought in these (2) incidents. The facility nurse, a licensed medical professional, was also called in to conduct a full body assessment for any signs of injury or for any signs of potential abuse. It was learned that R1 was also sent out to the emergency room for these (2) incidents as well for precautionary reasons.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

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-20211116150852

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: AUSTIN ROAD HOME	FACILITY NUMBER: 392700603
	VISIT DATE: 03/28/2022

NARRATIVE

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In addition, based on statements, written or orally, it was learned that facility staff felt that the environment they presented to the facility residents was one of a home-like surrounding able to support their needs while maintaining adequate care and supervision.
Based on observations by this LPA while present at this facility, it was observed that facility residents were eager to approach the facility staff for assistance or attention. Facility residents were observed to be comfortable and able to express their emotions to the staff. Facility residents were observed to able to act accordingly to their own thoughts and decisions.
Based on a review of information in regards to a resident sustaining an injury while under the care of this facility, it was learned the resident in question, and the type of injury, did not take place at this facility location. That particular incident took place at another licensed care facility under the same Licensee.

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

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022

LIC9099 (FAS) - (06/04)

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