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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701033
Report Date: 11/14/2022
Date Signed: 11/15/2022 08:19:07 AM

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
09/15/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220915170550
FACILITY NAME:ST. RITA CARE HOMEFACILITY NUMBER:
392701033
ADMINISTRATOR:TALONGWA, CATHERINEFACILITY TYPE:
740
ADDRESS:3478 LADD TRACT CT.TELEPHONE:
(650) 465-2526
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 3DATE:
11/14/2022
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Karrene WindethTIME COMPLETED:
11:58 AM
ALLEGATION(S):
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9
Staff pinched resident
Resident sustained injury while in care.
INVESTIGATION FINDINGS:
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LPA Albert Johnson conducted an unannounced visit to deliver findings for the allegations listed above.

Based on records reviewed from the San Joaquin General Hospital, R1 was sent to the ER for Acute lower urinary tract infection and abdominal pain. The records indicated that R1 was assessed for signs or systoms of abuse or neglect and there were no concerns.

The ER noted that R1 was admitted on 9/15/2022 and discharged on 9/27/2022 to a long term care hospital.

Continued
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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 3
Control Number 27-AS-20220915170550
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: ST. RITA CARE HOME
FACILITY NUMBER: 392701033
VISIT DATE: 11/14/2022
NARRATIVE
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R1 was placed on a psychiatric hold prior to being discharged. The facility records also indicated that R1 would hit the walls, wheelchair and the doors which could account for the bruising on R1.

Staff and Administrator denied witnessing R1 being pinched or otherwise mistreated while at the facility.

Based on interviews, observations, and record reviews it is determined that there is not a preponderance of evidence to prove that Staff pinched resident. Additionally, there is not a preponderance of evidence to prove Resident sustained injury while in care. As a result, the above allegations are UNSUBSTANTIATED.

An exit interview was conducted
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
09/15/2022 and conducted by Evaluator Albert Johnson
COMPLAINT CONTROL NUMBER: 27-AS-20220915170550

FACILITY NAME:ST. RITA CARE HOMEFACILITY NUMBER:
392701033
ADMINISTRATOR:TALONGWA, CATHERINEFACILITY TYPE:
740
ADDRESS:3478 LADD TRACT CT.TELEPHONE:
(650) 465-2526
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY:6CENSUS: 3DATE:
11/14/2022
UNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Karrene WindethTIME COMPLETED:
11:58 AM
ALLEGATION(S):
1
2
3
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5
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9
Facility is unkempt.
INVESTIGATION FINDINGS:
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Based on mulipty visits and observation during these visits the facility is well kept. The facility is clean, safe, sanitary and in good repair during my visits. The facility has and procedures for the safety and the well-being of residents, employees and visitors.

LPA observed floor surfaces in bath, laundry and kitchen areas were maintained, clean, sanitary, and odorless condition. LPA also observed and experienced a comfortable temperature for residents.

“This agency has investigated the complaint alleging, “Facility is unkempt.”. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”
Unfounded
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3