397005738-8-12-2021-27-AS-KHOS-C67KRS-20210824080824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 397005738
Report Date: 08/12/2021
Date Signed: 08/12/2021 11:39:36 AM

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
07/20/2021 and conducted by Evaluator Michael Bilger

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210720100540

FACILITY NAME:	INSPIRING CARE		FACILITY NUMBER:	397005738
ADMINISTRATOR:	PUCKETT, VICTORIA		FACILITY TYPE:	735
ADDRESS:	2488 NATHANIEL STREET		TELEPHONE:	(209) 951-2405
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY:	5	CENSUS: 4	DATE:	08/12/2021
		UNANNOUNCED	TIME BEGAN:	11:22 AM
MET WITH:	Carrie Mumphrey		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

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Staff caused an injury to client during an altercation

Staff did not properly report an incident involving a client

INVESTIGATION FINDINGS:

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On 8/12/21 at 11:22am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations listed above. LPA met with Administrator Carrie Mumphrey and explained the purpose of this visit. During the course of this investigation, LPA reviewed facility documentation including but not limited to: Physician reports, staffing roster, resident roster, smoking policy, house rules, and program plan.
Allegation #1: Staff caused an injury to a resident during a physical altercation. LPA interviewed Resident(R1), R2 and R3 as well Staff1 (S1), S2, and S3. LPA also interviewed Licensee. LPA also reviewed resident records and facility file documentation. Based on interviews and record reviews on 7-26-21, 7-28-21 and 8-4-21 it was revealed that the alleged victim (resident) denied claims of being involved in a physical altercation and being hit and shoved by any staff member. Interviews also revealed that there were no factual witnesses to a physical altercation between a resident and staff member. LPA did not observe any bruising marks on residents in care.

{Cont. on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

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-20210720100540

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: 08/12/2021

NARRATIVE

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Record reviews did not reveal any reports of bruising or pain for residents in care. Based on interviews, record reviews, and observation it is determined that the preponderance of evidence standard is not met, therefore, this allegation is UNSUBSTANTIATED.

Allegation #2: Staff did not properly report an incident involving a resident. LPA reviewed facility records of incident reports and conducted interviews regarding incident reporting. During record review on 7-28-21, an incident report for the above allegation of staff caused an injury to resident during a physical altercation was not located. LPA interviewed Licensee on 8-4-21. Based on interview, it was revealed that an incident report was sent to the Department on 7-20-21. Licensee was able to produce a fax confirmation sheet on 8-4-21 at 4:39pm which also indicated an incident report described as a report for the alleged victim sent on 7-20-21 at 12:54pm to fax number (916) 263-4744. Based on interview and record review it is determined that the preponderance of evidence standard is not met, therefore, this allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021

LIC9099 (FAS) - (06/04)

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