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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392701157
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:14:55 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
10/31/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20221031172127
FACILITY NAME:MOTHER MARY CARE HOMEFACILITY NUMBER:
392701157
ADMINISTRATOR:ALVAREZ, JEANFACILITY TYPE:
740
ADDRESS:492 E. FRISBEE LANETELEPHONE:
(209) 888-4080
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:6CENSUS: 4DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jean AlvarezTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff do not respond to resident's requests for assistance in a timely manner.
Staff do not ensure that resident has a way to request assistance from staff while in care.
INVESTIGATION FINDINGS:
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On 11/9/22 at 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegations. LPA Jensen met with Administrator Jean Alvarez and explained the purpose of today's visit.

LPA Jensen observed the facility to be clean and free of odor upon arrival. There was a sign in table observed and all required postings were observed. LPA Jensen checked the food supply and observed teh facility to have 2 days of perishable food and 7 days of non-perishable food. LPA Jensen interviewed Administrator Jean Alvarez regarding the telephone service and resident care. She stated that residents are checked on every 30 minutes to one hour and are turned every 2 hours. Resident 1 (R1) has a call button that sends an alert to the kitchen. LPA Jensen checked the call button and determined it to be in good working order. Administrator Jean Alvarez was unable to confirm the date the call button was put in to place.
Continued on LIC 9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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 6
Control Number 27-AS-20221031172127
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: MOTHER MARY CARE HOME
FACILITY NUMBER: 392701157
VISIT DATE: 11/09/2022
NARRATIVE
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LPA Jensen interviewed 4 of 4 residents. 3 of 4 residents advised they always receive any assistance they need in a timely manner. 3 of 4 residents advised they have the ability to communicate with whomever they choose whenever they choose.

LPA Jensen interviewed a San Joaquin County hospice worker and was advised she has no concerns about the quality of care. LPA Jensen also interviewed Staff 1 (S1) who stated that residents are checked every 30 - 60 minutes.

Based on interviews conducted with 4 of 4 clients, 1 hospice worker and 2 staff, the allegation of staff do not respond to resident's requests for assistance in a timely manner has been found to be UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

Based on interviews with 4 of 4 residents, interviews with 2 staff members and a test of the call button, the allegation of staff do not ensure that resident has a way to request assistance from staff while in care is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

An exit interview was conducted and a copy of this report was provided to the administrator.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/31/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20221031172127

FACILITY NAME:MOTHER MARY CARE HOMEFACILITY NUMBER:
392701157
ADMINISTRATOR:ALVAREZ, JEANFACILITY TYPE:
740
ADDRESS:492 E. FRISBEE LANETELEPHONE:
(209) 888-4080
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:6CENSUS: 4DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jean AlvarezTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility phone system is in disrepair.
INVESTIGATION FINDINGS:
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On 11/9/22 at 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegations. LPA Jensen met with Administrator Jean Alvarez and explained the purpose of today's visit.

LPA Jensen called the facility telephone and determined there was no issue with receiving calls. LPA Jensen had the Administrator call her from the facility phone and found there was no issue placing outgoing calls.

Based on LPA Jensen's test of the facility phone system this allegation is UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, or is without a reasonable basis.

An exit interview was conducted and a copy of this report was given to the Administrator.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/31/2022 and conducted by Evaluator Maja Jensen
COMPLAINT CONTROL NUMBER: 27-AS-20221031172127

FACILITY NAME:MOTHER MARY CARE HOMEFACILITY NUMBER:
392701157
ADMINISTRATOR:ALVAREZ, JEANFACILITY TYPE:
740
ADDRESS:492 E. FRISBEE LANETELEPHONE:
(209) 888-4080
CITY:FRENCH CAMPSTATE: CAZIP CODE:
95231
CAPACITY:6CENSUS: 4DATE:
11/09/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Jean AlvarezTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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2
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9
Staff do not ensure that resident has the ability to communicate with others.
INVESTIGATION FINDINGS:
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On 11/9/22 at 10:15am Licensing Program Analyst (LPA) Maja Jensen arrived at facility unannounced to open a complaint investigation in to the above listed allegations. LPA Jensen met with Administrator Jean Alvarez and explained the purpose of today's visit.

LPA Jensen determined there is a facility telephone that is in working order however there were 67 messages that had not been retreived. LPA Jensen interviewed Administrator Jean Alvarez who advised they are having a problem with the telephone system going straight to voicemail. The telephone system had been programmed to go to voicemail after two rings. In the presence of the LPA, the telephone was adjusted to go to voicemail after 6 rings.

Based on LPA's Jensen observation of 67 unretreived voicemails, one of which was from the LPA herself, the allegation that staff do not ensure that resident has the ability to communicate with others is SUBSTANTIATED. Continued on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
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 6
Control Number 27-AS-20221031172127
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: MOTHER MARY CARE HOME
FACILITY NUMBER: 392701157
VISIT DATE: 11/09/2022
NARRATIVE
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If friends, family or care providers call the facility and leave messages for the residents, the messages are not being retrieved or relayed to the residents. A finding of substantiated means that the preponderance of evidence standard has been met.

Citations are being issued from the California Code of Regulations, Title 22, Division 6.

An exit interview was conducted and a copy of this report and appeal rights were given to the facility Administrator.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20221031172127
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: MOTHER MARY CARE HOME
FACILITY NUMBER: 392701157
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/11/2022
Section Cited
CCR
87468.1(a)(14)
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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:
(14) To have reasonable access to telephones, to both make and receive confidential calls...This requirement was not as evidenced by:
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Licensee conducted an inservice training on use of the facility answering machine in the presence of LPA Jensen. No further Plan of Correction is required
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LPA Jensen's observation of 67 unretreived voicemails. This poses a potential health, safety and personal rights risk to residents in care.
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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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Maja JensenTELEPHONE: 916-639-5584
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6