405801962-11-17-2021-29-AS-KBUY-C92QRF-20211123112353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 405801962
Report Date: 11/17/2021
Date Signed: 11/17/2021 12:30:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2020 and conducted by Evaluator Rachael De Leon

COMPLAINT CONTROL NUMBER: 29-AS-20200408151730

FACILITY NAME:	SINGLETREE CARING HANDS		FACILITY NUMBER:	405801962
ADMINISTRATOR:	HEATHER WHITE		FACILITY TYPE:	740
ADDRESS:	1789 SINGLETREE COURT		TELEPHONE:	(805) 540-8408
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93405
CAPACITY:	6	CENSUS: 5	DATE:	11/17/2021
		UNANNOUNCED	TIME BEGAN:	12:09 PM
MET WITH:	Staff Nancy Naguit		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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Residents needs are not being met due to staff not changing them during the night
The facility does not have an adequate food supply on hand 7 days a week

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) De Leon conducted a subsequent complaint visit to the facility above.
LPA met with Staff as Administrator was not able to meet with LPA at this time. LPA called Administrator and explained the purpose of the visit. Administrator gave authorization for staff to sign report.

LPA interviewed Staff on 04/08/2020 between 4:30-4:45pm, on 04/20/2020 around 2:01 pm, on 04/21/2020 around 10:52 pm, on 05/28/2020 around 10:36 am and on 10/11/2021 at 4:16 pm. LPA interviewed witnesses on 10/11/2021 at 4:55 pm.
LPA virtually toured the facility and observed the food supply on 04/08/2020 around 4:18 pm and on 11/17/2021 at 12:15 pm.
Continued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

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 29-AS-20200408151730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SINGLETREE CARING HANDS	FACILITY NUMBER: 405801962
	VISIT DATE: 11/17/2021

NARRATIVE

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LPA requested records on 04/08/2020 around 4:30pm. LPA reviewed records on 04/08/2020 and 10/11/2021.

On the allegation: Residents needs are not being met due to staff not changing them during the night. LPA interviewed staff which revealed that staffing was down to 1 caregiver per shift at the facility. The caregiver was responsible to do all the cooking, cleaning and care giving for 5-6 residents. Staff revealed that some staff could not change a few residents during the NOC shift by themselves, so they waited till staff arrived in the AM shift to help. Based on the evidence this allegation is deemed Substantiated at this time.

On the allegation: The facility does not have an adequate food supply on hand 7 days a week. LPA interviewed staff and witnesses which revealed they would run out of groceries regularly, they were not able to make planned meals due to being out of required ingredients, items were changing for less expensive brands or not being purchased any longer, portion sizes for residents were less. LPA toured the food supply on 04/08/2020 and it was not an adequate amount of food for 6 residents to have 3 full meals and 2 snacks a day and the backup emergency food supply was insufficient to meet the needs of 6 residents. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Licensee/Administrator for signature and return to the Goleta office.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200408151730

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SINGLETREE CARING HANDS	FACILITY NUMBER: 405801962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/18/2021 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	(f)Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to have all staff read, review and watch videos on Care and Supervision of residents on Incontinence, Toileting, Feeding, Changing, Residents Personal Rights... continued below...
	8 9 10 11 12 13 14	Based on staff interviews the Licensee did not comply with regulations by allowing staff not to toilet or change residents’ briefs during the NOC shift which poses an immediate health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	and provide a list of regulations reviewed, videos watched and all staff listed on the LIC 500 and CCL’s Facility Personnel Roster signatures.
Type B 11/24/2021 Section Cited CCR 87555(c)	1 2 3 4 5 6 7	(c)...provide written information as to the foods purchased...,based upon documentation, there is reason to believe that the food service requirements are not being met. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to ask residents food likes/dislikes, make a weekly menu for breakfast, lunch, dinner and 2 snacks daily and purchase groceries to accommodate the menu...continued below.
	8 9 10 11 12 13 14	Based on observations and interview the Licensee did not comply, the food supply was low on several occasions which poses a potential health, safety and personal rights risk to residents in care.	8 9 10 11 12 13 14	and serving 5 residents in care. Provide copies of menu and grocery receipts for 1 month to CCL.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021

LIC9099 (FAS) - (06/04)

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