397002694-5-24-2023-27-AS-KHOS-CSJJY2-20230606072715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397002694
Report Date: 05/18/2023
Date Signed: 05/24/2023 10:55:55 AM

Substantiated

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
04/05/2023 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230405142636

FACILITY NAME:	HOME SWEET HOME FOR THE ELDERLY		FACILITY NUMBER:	397002694
ADMINISTRATOR:	SUZARA, SARAH		FACILITY TYPE:	740
ADDRESS:	14110 JASPER STREET		TELEPHONE:	(209) 470-7772
CITY:	LATHROP	STATE: CA	ZIP CODE:	95330
CAPACITY:	6	CENSUS: 5	DATE:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	12:04 PM
MET WITH:	Sarah Suzara		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident eloped from facility due to lack of supervision
Staff blocked resident's door with a couch

INVESTIGATION FINDINGS:

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Based on the interview with the Administrator, R1 did leave the facility and was missing for an unknown amount of time on 3/12/2023. R1 was brought back to the facility by the local Paramedics at approximately 6:45am on 3/13/2023

The Administrator stated that R1 was unable to speak English and was having a difficult time developing relationships with her peers. She also stated that R1 was having problems sleeping and would be awake until 2:30am or later. On 3/12/2023 R1 went AWOL from the facility and was missing until she was returned by the local Paramedics on 3/13/2023. Staff was sleeping when R1 went missing.

The Administrator confirmed that they used the couch to block R1 into her room as a last resort to keep her and the other residents from having physical confrontations. Continued

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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-20230405142636

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: HOME SWEET HOME FOR THE ELDERLY	FACILITY NUMBER: 397002694
	VISIT DATE: 05/18/2023

NARRATIVE

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Based on interview with the Administrator and review of records the above allegations were SUBSTANTIATED meaning that there was a preponderance of evidence to prove that the allegations occurred as alleged.

The following deficiencies were cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with facility representative and a copy of this report was provided along with appeal rights.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230405142636

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: HOME SWEET HOME FOR THE ELDERLY	FACILITY NUMBER: 397002694
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/19/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a)- Personnel Requirements - General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.-This requirement is not met by interviews conducted and records review	1 2 3 4 5 6 7	The facility shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL
	8 9 10 11 12 13 14	R-1 AWOL'd from the facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.	8 9 10 11 12 13 14	and a signature sheet of all staff who attended. The Administrator will email the date of the in-service training to LPA by 05/19/23 to meet the 24 hour POC requirement.
Type B 05/26/2023 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 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:	1 2 3 4 5 6 7	The facility administrator will ensure that all staff receive in-service training regarding the personal rights of the clients and proof of this training will be submitted to CCL by the POC due date.
	8 9 10 11 12 13 14	(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. R1 was blocked in the room by a couch. Although it was to prevent a confrontation and used as a last resort. It was a rights violation.	8 9 10 11 12 13 14

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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

LIC9099 (FAS) - (06/04)

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