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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005738
Report Date: 07/28/2022
Date Signed: 07/28/2022 04:08:01 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
07/12/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220712153932
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:
07/28/2022
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Carrie MumphreyTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff not treating residents with dignity and respect
INVESTIGATION FINDINGS:
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On 7-28-22 at 3:10pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegation listed above. LPA met with Carrie Mumphrey and explained the purpose of the visit. Administrator William Puckett was made aware of LPA's visit. During this investigation, LPA interviewed Administrator, Staff1 (S1), S2 and S3. LPA also interviewed Resident1 (R1), R2, and R3. Additionally, LPA reviewed incident report for R1 dated 7-13-22, physician’s report for R1, Individualized Program Plan (IPP) for R1, service plan for R1, and Care notes for R1. LPA also conducted a facility observation on 7-13-22. Based on interviews and record reviews, it was indicated that an incident occurred on 7-12-22 which included a staff member being overheard by another staff member using profanity towards R1 during R1’s behavior episode. Based on interviews and record reviews, there is a preponderance of evidence to conclude that R1 was not treated with dignity and respect by a staff member of the facility. Therefore, this allegation is SUBSTANTIATED.
As a result of this investigation, citations are issued under Title 22, Division 6. An exit interview was conducted with Carrie Mumphrey and a copy of this report was left with Carrie. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
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 4
Control Number 27-AS-20220712153932
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: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2022
Section Cited
CCR
80072(a)(1)
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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: (1)To be accorded dignity in his/her personal relationships with staff and other persons. This requirement was not met as evidenced by:
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Licensee will read regulation 80072(a)(1) and submit a signed declaration of understanding to LPA by POC due date.

Licensee will conduct staff training on resident rights including dignity and respect, and submit proof of completed training to LPA by POC due date.
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Based on interviews and record review, a staff member used profanity towards R1 during R1’s behavior episode on 7-12-22. This poses a potential health, safety, and resident rights 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: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/12/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220712153932

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:
07/28/2022
UNANNOUNCEDTIME BEGAN:
03:10 PM
MET WITH:Carrie MumphreyTIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Residents are being inappropriately handled.
Staff hits resident in care.
Staff not providing adequate supervision to residents in care.
INVESTIGATION FINDINGS:
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This is an ammended report from an original 9099A form dated 7-28-22: On 7-28-22 at 3:10pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegation listed above. LPA met with Carrie Mumphrey and explained the purpose of the visit. Administrator William Puckett was made aware of LPA's visit. During this investigation, LPA interviewed Administrator, Staff1 (S1), S2 and S3. LPA also interviewed R1, R2, and R3. LPA also interviewed complainant. Additionally, LPA reviewed incident report for R1 dated 7-13-22, physician’s report for R1, Individualized Program Plan (IPP) for R1, service plan for R1, and Care notes for R1. LPA also conducted a facility observation on 7-13-22.
Allegation #1: Residents are being inappropriately handled. Based on interviews conducted, it was indicated that residents are being handled in an appropriate manner, and furthermore, based on interviews, there have been no witnesses to inappropriate handling by staff towards residents such as slamming or choking a resident. Interviews revealed that residents are redirected using verbal utilization. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220712153932
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: 07/28/2022
NARRATIVE
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Facility observation conducted by LPA revealed no observation of inappropriate staff interaction or handling by staff members. LPA observed redirection by staff members without physical contact. A review of incident report for R1 dated 7-13-22 and associated interviews conducted revealed no witnessing to inappropriate physical handling. Based on interviews and record reviews, there is not a preponderance of evidence to conclude that inappropriate handling of residents occurred at the facility. Therefore this allegation is UNSUBSTANTIATED.

Allegation #2: Staff hits resident in care. Based on interviews conducted and records reviewed, it was indicated that there have been no witnesses to any staff member hitting or slapping residents in care. Furthermore, based on interviews, it was not verbalized by residents that staff hits or slaps them. An observation by LPA revealed a noted bruise on R1’s left shoulder which R1 stated occurred outside the facility by an unidentified individual which has since been separately investigated. LPA also conducted observation of staff interaction with residents and did not observe any hitting, slapping, or other inappropriate physical contact by staff to residents in care. Interviews conducted could not determine the exact cause of the bruise. Based on record review and interviews, it was indicated that R1 has a history of falls and imbalance within facility as well as elopement attempts. Based on interviews, observation, and record review, there is a not a preponderance of evidence to conclude that R1 or other residents were hit by staff while in care, therefore, this allegation is UNSUBSTANTIATED.

Allegation #3: Staff not providing adequate supervision to residents in care. This allegation stated R1 “ran away” on 7-12-22 and “found later that morning” on 7-13-22. Based on staff and resident interviews, and record reviews, it was indicated that on 7-12-22, R1 engaged in an attempted elopement but returned to facility with staff supervision after being followed. LPA also conducted a facility observation on 7-13-22 and observed 2 staff members on duty for 4 residents. LPA further observed appropriate interaction by staff including verbalized redirection, prompts for care needs, and personal needs reminders to residents in care. Additionally, LPA observed resident access to bathrooms and own rooms as well as other common areas within facility. Based on interviews, record reviews, and observation, there is not a preponderance of evidence to conclude that staff was not providing adequate supervision to residents in care on 7-12-22 and 7-13-22. Therefore, this allegation is UNSUBSTANTIATED.

Based on this investigation, no citations are issued. 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: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4