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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005738
Report Date: 07/24/2024
Date Signed: 07/24/2024 11:36:20 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/24/2024 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240624085906
FACILITY NAME:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:PUCKETT, VICTORIAFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: ZIP CODE:
95210
CAPACITY:5CENSUS: 4DATE:
07/24/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Lynette More TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff physically abused resident.
Staff is keeping resident from moving.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived unannounced to deliver findings on this complaint investigation. LPA Lewis met with facility staff and explained the purpose of the visit.

Based on the interviews and statements obtained during the investigation process, the allegations are substantiated.
Allegation 1: Staff physically abused resident is found to be SUBSTANTIATED. Based on interviews with staff and residents three (3) staff members confirmed S1 was verbally and physical abusive toward residents.

Allegation 2: Staff is keeping resident from moving is found to be SUBSTANTIATED. Based on LPA'S observation R1's phone was locked in a safe that all staff did not have access to.

See 9099C page.....
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
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 3
Control Number 27-AS-20240624085906
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: INSPIRING CARE
FACILITY NUMBER: 397005738
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/25/2024
Section Cited
CCR
80072(A)(3)
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80072 (A)(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting....
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Licensee agrees that facility will provide staff with personal rights training and provide proof of completion or an anticipated completion by due date 7/25/24. if an anticipated due date is sent then proof will follow by date provided.
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This requirement was not met as evidenced by: Interviews with staff confirm residents were abused while in care. This posed an immediate health and safety risk to residents in care.
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Type A
07/25/2024
Section Cited
CCR
85072(B)(6)
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Personal Rights: (b) The licensee shall insure that each client is accorded the following personal rights. (3) To have communications to the facility from his/her relatives or authorized representative answered promptly and completely. The following regulation was not met as observed by:

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Licensee agrees that facility will provide the code for the safe to all staff. A Signed agreement of this will be submitted to the CCL Office by the due date of 7/25/24.
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Based on interviews and LPA observations R1'S phone was locked in a safe and not all employees had access to open the safe if R1 requested to use the phone. This poses a potential risk to resident's rights.
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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: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20240624085906
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: INSPIRING CARE
FACILITY NUMBER: 397005738
VISIT DATE: 07/24/2024
NARRATIVE
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The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegations are substantiated.

The following deficiency is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was given.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3