392701278-3-28-2024-27-AS-LKIG-D4CT6C-20240415142656

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701278
Report Date: 03/28/2024
Date Signed: 03/28/2024 12:25:10 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2024 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20240220112431

FACILITY NAME:	CHEROKEE RETIREMENT HOME		FACILITY NUMBER:	392701278
ADMINISTRATOR:	SINGH, JAGTAR		FACILITY TYPE:	740
ADDRESS:	4124 CHEROKEE RD		TELEPHONE:	(209) 518-1908
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95215
CAPACITY:	0	CENSUS: 0	DATE:	03/28/2024
		UNANNOUNCED	TIME BEGAN:	10:54 AM
MET WITH:	Jagtar Singh		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Staff leaves residents soaked in urine all night long
Facility does not provide a safe environment for the residents

INVESTIGATION FINDINGS:

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On 3-28-24 at 10:54am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with Administrator Jagtar Singh via phone and explained the purpose of the visit. Administrator gave permission for staff1 (S1) to view report and sign in his absence. During this investigation, LPA conducted interviews with three staff members and five residents in care. LPA also reviewed facility file documentation including physician reports, needs and service plans, staffing plan, and facility sketch. Additionally, LPA conducted a facility observation on 2-22-24.
Allegation: Staff leaves residents soaked in urine all night long. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that facility staff are currently providing incontinence care for two residents with regular checks during the day and night to ensure needs are met. It was additionally revealed through interviews, that resident1 (R1) receives attempted incontinence care, however, R1 regularly refuses care procedures at night per established regulatory resident rights. Further interviews revealed the facility staff are meeting the needs of other residents in care adequately at this time. {Cont. on 9099C}

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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-20240220112431

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CHEROKEE RETIREMENT HOME	FACILITY NUMBER: 392701278
	VISIT DATE: 03/28/2024

NARRATIVE

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As a result, there is not a preponderance of evidence existing which reveals facility staff are willfully leaving residents soaked in urine at night, therefore this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility does not provide a safe environment for the residents. LPA conducted interviews and record reviews as noted above. LPA also conducted a facility observation as noted above. Based on interviews, record reviews, and observation, it was determined that facility received an approved fire inspection last updated 2-26-24. Facility sketch reviewed revealed consistency between the sketch and physical facility layout. Additionally, it was revealed that the facility maintains a staff presence 24 hours per day, 7 days per week. Facility observation revealed railings and grab bars in appropriate locations within the facility and per regulatory requirements as well as adequate lighting in place for outside porch areas. Non-skid mats and grab bars were observed in bathrooms during facility observation and no obstructions to fire exits were noted. Interviews conducted revealed a presence of safety within the facility at this time. As result, there is not a preponderance of evidence to conclude that the facility currently is not or has not provided a safe environment for residents in care, therefore, this allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with S1 and a copy of this report was provided to S1. Appeal rights provided.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC9099 (FAS) - (06/04)

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