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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005738
Report Date: 10/11/2024
Date Signed: 10/11/2024 01:51:39 PM

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
08/05/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20240805090404
FACILITY NAME:INSPIRING CAREFACILITY NUMBER:
397005738
ADMINISTRATOR:WILLIAM PUCKETTFACILITY TYPE:
735
ADDRESS:2488 NATHANIEL STREETTELEPHONE:
(209) 951-2405
CITY:STOCKTONSTATE: ZIP CODE:
95210
CAPACITY:5CENSUS: 0DATE:
10/11/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:William PuckettTIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Resident AWOL resulting in hospital visit
Facility did not report incident to CCL
Insufficient Staffing
Personal rights were violated
INVESTIGATION FINDINGS:
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On 10-11-24 at 11:15am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the complaint allegations noted above. LPA met with Administrator William Puckett and explained the purpose of the visit. During this investigation, LPA conducted interviews with Administrator and three additional staff members. LPA also conducted record reviews including physician’s reports, individualized program plans (IPP), needs and service plans, and behavior interventions plans pertaining the resident1 (R1) and R2.
Allegation: Resident AWOL resulting in hospital visit. LPA conducted interviews and record reviews as indicated above. Based on interviews and record reviews, it was determined that in July 2024, R1 exited facility and continued to walk away from facility despite redirection attempts. It was further determined that staff on duty was unable to follow R1 for supervision and lost sight of R1 resulting in an absence of supervision.
{Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
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 5
Control Number 27-AS-20240805090404
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: 10/11/2024
NARRATIVE
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It was later revealed through record reviews that R1 did not return to the facility and admitted to the hospital after her absence without leave (AWOL), and later admitted to another licensed care home. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D. An immediate civil penalty in the amount of $1000 is issued in addition to the citation due to absence of supervision a repeat violation of Section 80078(a) within a 12-month period.

Allegation: Facility did not report incident to CCL (Community Care Licensing). LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that R1 exited facility in July 2024 and later admitted to the hospital as a result. Record reviews further revealed that an incident report for this event was not received by community care licensing. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D.

Allegation: Insufficient Staffing. LPA conducted interviews and record reviews as noted above. Based on interviews and record reviews, it was determined that in July 2024, R1 exited facility and continued to walk away from facility despite redirection attempts. It was further determined that staff on duty was unable to follow R1 for supervision and lost sight of R1 resulting in an absence of supervision. It was further revealed through interviews that at the time of the event, facility had one staff on duty temporarily as a scheduled one-on-one staff member assigned to R1 was late to arrive. Due to only one staff on duty, R1 was unable to be supervised during her absence without leave (AWOL) event, resulting in a lack of appropriate staffing and absence of supervision. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED. Citation is issued under Title 22, Division 6 and noted on LIC 9099D.

Allegation: Personal rights were violated.LPA conducted interviews and record reviews as noted above. Based on interviews, it was revealed that on at least one occasion during an outing R1 was given access to a staff member’s private residence for purposes of using the restroom. It was further revealed through interviews that R1 was, as a result of this event, placed in an unfamiliar environment with access to various supplies presenting a potential risk to health and safety. The preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240805090404
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: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2024
Section Cited
CCR
80078(a)
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80078(a). Responsibility for Providing Care and Supervision. (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:
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Licensee will submitted an updated plan which ensures proper supervision in the event of an AWOL. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, Licensee did not comply with the above requirement in that R1 exited facility once in the form of an AWOL during the month of July 2024 and was without supervision for a period of time until hospitalized. This posed an immediate health and safety risk to resident in care.
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Type B
10/21/2024
Section Cited
CCR
80061(b)(1)(E)
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80061(b)(1)(E). Reporting Requirements. (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours…(1) Events reported shall include…(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement was not met as evidenced by:
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Licensee will read regulation 80061(b)(1)(E) and submit a signed declaration of understanding to LPA by POC due date.
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Based on interview and record review, R1 AWOL’d during July 2024 and Licensee did not ensure a report was sent to licensing department per regulatory requirements. This posed a potential health and safety risk to resident in care.
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Licensee will submit a plan to ensure future reports are submitted to licensing department per regulatory requirements. Plan to be submitted to LPA by POC due date.
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: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20240805090404
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: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2024
Section Cited
CCR
80056(a)
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80056(a) Personnel Requirements. (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs. This requirement was not met as evidenced by:
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Licensee will develop and submit a plan ensuring on-going necessary coverage of staff in sufficient numbers to meet resident needs. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, a one-on-one staff member did not show up as scheduled and R1 exited facility in the form of an AWOL resulting in an absence of supervision. This posed an immediate health and safety risk to residents in care.
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Type B
10/21/2024
Section Cited
CCR
80072(a)(2)
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80072(a)(2). Personal Rights. (a)…each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations…This requirement was not met as evidence by:
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Licensee will read regulation 80072(a)(2) and submit a signed declaration of understanding to LPA by POC due date.

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Based on interview, R1 was allowed access to a staff member’s private residence to use the bathroom resulting in exposure to potential danger within an unfamiliar environment. This posed a potential health and safety risk to residents in care.
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Licensee will conduct staff training on resident rights including safe, healthful accommodations. Proof of completed training to be submitted to LPA by POC due date.
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: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240805090404
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: 10/11/2024
NARRATIVE
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Citation is issued under Title 22, Division 6 and noted on LIC 9099D.A civil penalty in the amount of $250 is issued in addition to citation due to a repeat violation of Section 80072(a)(2) within a 12-month period. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5