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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005738
Report Date: 06/14/2022
Date Signed: 06/14/2022 05:10:04 PM

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
06/10/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220610122057
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:
06/14/2022
UNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Carrie MumphreyTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff are mismanging resident's medications.
Staff are not properly storing resident's medications.
Facility door has inappropriate locks.
Facility is in disrepair.
Food is not adequately stored.
Facility does not have PPE supplies.
Facility is not following COVID-19 protocols.
INVESTIGATION FINDINGS:
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On 6-14-22 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a complaint investigation for the allegations noted above. LPA met with Assistant Administrator Carrie Mumphrey and explained the purpose of the visit. Licensee William Puckett was notified of LPA's visit by phone. LPA requested staffing roster, resident roster, medication logs for Resident1 (R1), R2, R3, and R4. LPA also conducted facility tour and reviewed additional facility documentation. LPA also interviewed assistant administrator and staff1 (S1).

Allegation #1: Staff are mismanaging resident's medications. LPA reviewed May and June 2022 medication logs and physician orders for R1, R2, R3, and R4. LPA also interviewed Assistant Administrator and S1. Based on record reviews and interviews, it was determined that documentation for medication indicated that R1 and R2 did not receive medications as ordered. Based on interviews and record reviews, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. (Cont. on 9099C).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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 7
Control Number 27-AS-20220610122057
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: 06/14/2022
NARRATIVE
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Allegation #2: Staff are not properly storing medication. LPA conducted facility tour and observed medication storage area and reviewed additional facility documentation containing photos of medication storage area. LPA observed medication storage area to contain medication stacked in a disorganized manner and used bubble pack medication containers and other items on the floor of the storage cabinet. Based on observation, this allegation is SUBSTANTIATED.

Allegation #3: Facility door has inappropriate locks. LPA conducted facility tour and observed a locking deadbolt mechanism and on front door. LPA also conducted interviews with Assistant Administrator and S1. Based on interviews and observation, it was determined that R1 has a history of exit seeking and deadbolt is locked from the inside to prevent R1 from exit seeking. LPA was unable to open door after it was locked with a key maintained by staff. Based on observation, this allegation is SUBSTANTIATED.

Allegation #4: Facility is in disrepair. LPA conducted facility tour inside and out. LPA observed torn carpeting and drywall on the edges of the top staircase. LPA also observed a loose banister on the top left of the staircase. LPA also conducted interview with Assistant Administrator. Based on observation and interview, this allegation is SUBSTANTIATED.

Allegation #5: Food is not adequately stored. LPA conducted facility tour of kitchen area including refrigerator and non-perishable storage area. LPA observed a left over food item in the refrigerator to be covered without a label and date. LPA observed a bag of flour in the non-perishable storage area exposed and not tightly closed. Based on observation, this allegation is SUBSTANTIATED.

Allegation #6: Facility does not have PPE supplies. LPA conducted facility tour and interview with Assistant Administrator. LPA observed PPE storage area to contain 1 box of masks and 1 box of gloves. Additionally, based on interview, it was revealed that PPE was provided by outside source on 6-9-22, and 30-day supply of PPE was not available at that time. LPA did not observe a 30-day supply of PPE during today's visit. Based on observation and interview, this allegation is SUBSTANTIATED.

{Cont. on 9099C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20220610122057
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: 06/14/2022
NARRATIVE
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Allegation #7: Facility is not following COVID-19 protocols. LPA arrived at facility and was not screened upon entry with temperature and COVID-19 screening questions. Additionally, LPA observed facility staff not properly wearing masks and taking masks off during intervals of communication with LPA. Based on observation, this allegation is SUBSTANTIATED.

Deficiencies are cited under Title 22, Division 6 and Health and Safety Codes. A civil penalty of $250 is issued due to repeat violation of Section 80070(a)(b)(10). An immediate civil penalty of $500 issued due to violation of Section 80072(a)(7). An exit interview was conducted with Carrie Mumphrey and a copy of this report was left with Carrie. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20220610122057
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: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2022
Section Cited
CCR
80070(a)(b)(10)
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Client Records. (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. (b) Each record must contain information including, but not limited to, the following:(10) Record of current medications...
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Licensee will conduct an audit to ensure medication records are complete and accurate. Licensee to submit audit to LPA by POC due date.

Licensee will submit a plan to ensure all medication documentation are current and accurate going forward. Plan to be submitted to LPA by POC due date.
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This requirement is not met as evidenced by: Based on observation and interview, medication log sheets for R1 and R3 were not complete and missing documentation for medications scheduled during May and June 2022 This poses a potential health and safety risk to residents in care. Repeat violation within 12-month period
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Type B
06/21/2022
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 re-organized medication closet in a sanitary and orderly manner. Licensee to submit photo proof to LPA by POC due date.

Licensee will read regulation 80072 and submit a signed declaration letter of understanding to LPA by POC due date.
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Based on observation and documentation review, medication storage closet was disorganized with used medication bubble packs and other items on floor of storage closet. This poses a potential 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: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20220610122057
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: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2022
Section Cited
CCR
80072(a)(7)
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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: (7) Not to be locked in any room, building, or facility premises by day or night. This requirement is not met as evidenced by:
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Licensee shall ensure front door is not locked from the inside and remove or modify locking mechanism to allow exiting. Licensee to submit photo proof to LPA by POC due date.

Licensee will read regulation 80072(a)(7) and submit a signed declaration of understanding to LPA by POC due date.
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Based on observation and interview, the front entry door of facility is locked from the inside to prevent residents from exiting. This poses an immediate health, safety, and resident rights risk to residents in care. Immediate civil penalty of $500 issued.
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Type B
06/24/2022
Section Cited
CCR
80087(a)
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Building and Grounds. (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
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Licensee will repair torn carpeting and drywall and submit photo proof to LPA by POC due date.

Licensee will repair or replace loose banister by POC due date. LPA to conduct POC visit prior to clearance.
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Based on observation and interview, LPA observed torn carpeting and drywall on the edges of the top staircase. LPA also observed a loose banister on the top left of the staircase. This poses a potential 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: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20220610122057
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: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2022
Section Cited
CCR
80076(18)
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80076 Food Services. (18) All food shall be protected against contamination. Contaminated food shall be discarded immediately. This requirement is not met as evidenced by:
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Licensee will submit a plan to ensure all food is properly stored and labled. Licensee to submit plan to LPA by POC due date.

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Based on observation, licensee did not ensure left over food in refrigerator was labeled with appropriate date. Additionally, Licensee did not ensure a bag of flour in food storage area was closed securely. This poses an immediate health and safety risk to residents in care.
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Type A
06/15/2022
Section Cited
CCR
80064(a)(3)
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Administrator Qualifications and Duties. (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation. This requirement is not met as evidenced by:
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Licensee will submit a plan to ensure all staff are following COVID precautions including COVID screening and PPE usage. Plan to be submitted to LPA by POC due date.

Licensee to conduct in-service training on COVID precautions. Proof of completed training to be submitted to LPA by POC due date.
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Based on observation, Licensee/Administrator did not ensure staff are following COVID precautions includng temperature check, COVID-19 screening questions, and wearing masks as appropriate while in presence of residents in care. 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: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20220610122057
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: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/15/2022
Section Cited
HSC
1550(c)
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1550(c): Licenses or administrator certificate:(c)Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home. This requirement is not met as evidenced by:
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Licensee will provide a 30-day supply of PPE to facility by POC due date and submit photo proof to LPA by POC due date. POC visit to follow prior to clearance.
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Based on observation and interview, Licensee does not possess at least a 30 day supply of PPE including face masks. 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: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7