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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005738
Report Date: 04/28/2022
Date Signed: 04/28/2022 04:18:10 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
04/05/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220405083355
FACILITY NAME:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:PUCKETT, VICTORIAFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:5CENSUS: 4DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Carrie MumphreyTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff pushed resident while in care
Uncleared staff caring and supervising residents
Staff sprays water at resident
Staff do not provide activities for residents
INVESTIGATION FINDINGS:
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On 4-28-22 at 1:25pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced continue investigation and deliver investigation findings for the allegations listed above. LPA met with assistant administrator Carrie Mumphrey and explained the purpose of the visit. Administrator William Puckett was made aware of LPA's visit. Throughout this investigation, LPA interviewed Resident1 (R1), R2, R3, and R4 as well Staff1 (S1) S2, and S3. LPA also reviewed individualized program plan (IPP) for R1, R2, and R4. LPA also reviewed facility’s activity schedule and personnel report and conducted facility observation. Additionally, LPA interviewed regional case manager and reviewed staff criminal record clearances.

Allegation #1: Staff pushed resident while in care. Allegation specifically stated R1 was pushed by a staff member off the couch. LPA interviewed R1, R2, R3, and R4 and S1, S2, and S3. LPA also reviewed IPP for R1, R2, and R4. Based on interviews and record reviews, it was determined that there has been no confirmed witnessing of staff pushing R1 or other residents in care either off a couch or in other settings within the facility. Furthermore, based on interviews, there were no confirmed reports of any residents experiencing being pushed by staff. As a result, there is a not a preponderance of evidence to confirm this allegation occurred. Therefore, this allegation is UNSUBSTANTIATED. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 5
Control Number 27-AS-20220405083355
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: INSPIRING CARE
FACILITY NUMBER: 397005738
VISIT DATE: 04/28/2022
NARRATIVE
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Allegation #2: Uncleared staff caring and supervising residents. Allegation stated that two specific caregivers, S5 and S6, have worked at the facility without criminal clearance. LPA reviewed criminal record clearance records through Guardian system and interviewed S1, S2, and S3, as well as R1, R2, R3, and R4 Based on interviews and records reviewed, it was determined that 1 of the 2 staff members had criminal clearance while working at the facility. S5 is determined to be cleared through Guardian system. Based on additional interviews, it was determined that S6 was not familiar to other staff members or residents as an individual who ever worked at the facility and her presence was denied through interviews. A record review of staff charts did not reveal a record for S6. Based on the records reviewed and interviews conducted, there is not a preponderance of evidence to prove that this individual worked in the facility without a criminal record clearance. Therefore, this allegation is UNSUBSTANTIATED.

Allegation #3: Staff sprays water at resident. LPA interviewed R1, R2, R3, and R4 as well as S1, S2, and S3. Allegation states a staff member sprays water at a resident during behavior episodes. Based on interviews conducted, it was determined that R1, R2, R3, and R4 denied experiencing or observing staff members spraying water at them. Based on interviews with S1, S2, and S3, it was determined that observations of staff spraying water at residents was denied. On 4-13-22, LPA observed behavior interventions by staff to include appropriate responses. As a result, there is not a preponderance of evidence to prove this allegation occurred. Therefore, this allegation is UNSUBSTANTIATED.

Allegation #4: Staff do not provide activities for residents. LPA reviewed facility’s activities schedule and interviewed R1, R2, R3, and R4. LPA also interviewed S1, S2, S3, and regional case manager for R4. Based on record reviews and interviews, it was determined that facility offers activities 4 times per day including but not limited to exercising, arts and crafts, and card games. Additionally, based on interviews, it was determined that various residents enjoy own leisure time with outside individuals such as families and friends as well as activities offered within facility. Based on the interviews conducted and record reviews, there is not a preponderance of evidence to prove resident do not receive activities as appropriate or scheduled, therefore, this allegation is UNSUBSTANTIATED.

An exit interview was conducted with Carrie Mumphrey and a copy of this report was given to Carrie.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/05/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220405083355

FACILITY NAME:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:PUCKETT, VICTORIAFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:5CENSUS: 4DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Carrie MumphreyTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Resident fell while in care
INVESTIGATION FINDINGS:
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On 4/28/22 at 1:25pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver investigation findings for the allegations listed above. LPA met with assistant administrator Carrie Mumphrey and explained the purpose of the visit. Administrator William Puckett was notified of LPA's visit. LPA reviewed IPP for R1 and interviewed S1, S2, and S3. LPA also interviewed R1 and conducted an observation of R1’s room. Based on interviews and record reviews, it was determined that R1 fell on facility premises on 4-12-22 and previously on 2-16-22. It was further determined that resident has a history of falling out of bed and in other areas of facility including R1’s room due to poor balance. Based on additional interviews, it was determined that a new bed frame was requested and in process of being replaced as of 3/23/22 as a component to aid in fall prevention, and based on interview, was replaced on 4-15-22. Record reviews of R1s IPP by LPA revealed that R1 is unaware of dangerous situations and requires 24-hour monitoring for care and safety. Additionally, IPP does not indicate a specific intervention for fall prevention at this time. Based on record reviews and interviews, it is determined that R1 had a fall at facility, and facility fall prevention methods were inadequate for R1. The preponderance of evidence standard is met, therefore this allegation is SUBSTANTIATED. Deficiencies are cited under Title 22. An exit interview was conducted with Carrie Mumphrey and a copy of this report was given to Carrie. Appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 5
Control Number 27-AS-20220405083355
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: INSPIRING CARE
FACILITY NUMBER: 397005738
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/29/2022
Section Cited
CCR
80072(a)(2)
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Personal Rights. (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidenced by:
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Licensee will update R1's IPP to reflect specific interventions for fall prevention. Licensee to submit updated IPP to LPA by POC due date.

Licensee will ensure staff training on fall prevention is completed. Licensee to submit proof of completed training to LPA by POC due date.
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Based on interviews and record reviews, R1 sustained a fall at facility on 2-16-22 and 4-12-22 prior to bed frame replacement, and additional fall prevention methods which are not currently present on individualized program plan (IPP). This poses an immediate health and safety 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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5