392701374-8-16-2024-27-AS-KHOS-D8JKPB-20240827080427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392701374
Report Date: 08/16/2024
Date Signed: 08/16/2024 01:25:07 PM

Unfounded

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
08/14/2024 and conducted by Evaluator Michael Bilger

COMPLAINT CONTROL NUMBER: 27-AS-20240814161949

FACILITY NAME:	CHEROKEE RETIREMENT HOME INC		FACILITY NUMBER:	392701374
ADMINISTRATOR:	SINGH, JAGTAR		FACILITY TYPE:	740
ADDRESS:	4124 CHEROKEE ROAD		TELEPHONE:	(209) 518-1908
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95215
CAPACITY:	15	CENSUS:	DATE:	08/16/2024
		UNANNOUNCED	TIME BEGAN:	10:27 AM
MET WITH:	Cecilia Nunez		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not prevent resident from eloping
Licensee did not provide responsible party with a refund

INVESTIGATION FINDINGS:

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On 8-16-24 at 10:27am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate the complaint allegations noted above. LPA met with Cecilia Nunez (S1) and explained the purpose of the visit. LPA spoke with Administrator Jagtar Singh via phone and explained the purpose of the visit. During this investigation, LPA conducted interviews with Administrator, staff1 (S1) and additional witness. LPA also reviewed facility file documentation including resident appraisal, physician's report, and admission agreement for resident1 (R1).

Allegation: Staff did not prevent resident from eloping. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that R1 admitted to facility on 8-7-24 after admission agreement signed on same day. R1 arrived via non-emergency transport and entered the facility. Shortly thereafter, R1 exited facility but remained on grounds and seated self outside near facility entrance. Interviews further revealed that R1 was supervised by staff throughout the evening on 8-7-24 providing food and blankets. {Cont. on 9099C}

Unfounded

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: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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-20240814161949

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 INC	FACILITY NUMBER: 392701374
	VISIT DATE: 08/16/2024

NARRATIVE

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On this same evening, Administrator determined R1 required further evaluation due to increased confusion and notified emergency personnel who arrived and transported R1 to hospital. A review of R1's physician's report does not indicate a history of wandering or elopement behavior. Based on interviews and record reviews, it was determined that R1 did not elope from facility, therefore, the preponderance of evidence standard is not met and this allegation is UNFOUNDED.

Allegation: Licensee did not provide responsible party with a refund. LPA conducted interviews and record reviews as stated above. Based on admission agreement, R1's responsible party signed the agreement on 8-7-24 coinciding with the date of R1's admission date. Based on interviews, R1 was sent to the hospital on 8-7-24 shortly after admission for a re-evaluation due to behaviors. Licensee and staff provided supervisory services and meals to R1 during his stay. A review of R1's physician's report does not indicate a history of wandering or elopement behavior. Interviews further revealed that although Licensee is willing to accept R1 back pending stabilization, hospital staff and R1's responsible party have opted for placement elsewhere at this time. Interviews and record reviews revealed R1 did not furnish a 30-day notice to move at this time. As a result, there is not a preponderance of evidence to conclude Licensee is entitled to issue a refund to R1, therefore, this allegation is UNFOUNDED.

An exit interview was conducted with S1 and a copy of this report was provided to R1.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Michael Bilger	TELEPHONE: (916) 862-4722
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC9099 (FAS) - (06/04)

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