425801082-3-7-2022-29-AS-KBUY-CCEV5K-20220311150805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425801082
Report Date: 03/07/2022
Date Signed: 03/07/2022 04:09:54 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
07/03/2020 and conducted by Evaluator Jeannette Olson

COMPLAINT CONTROL NUMBER: 29-AS-20200703123416

FACILITY NAME:	SUPERIOR RESIDENTIAL CARE FOR THE ELDERLY II		FACILITY NUMBER:	425801082
ADMINISTRATOR:	ERIC SO HU		FACILITY TYPE:	740
ADDRESS:	876 BLAKE STREET		TELEPHONE:	(805) 268-4787
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93455
CAPACITY:	6	CENSUS: 4	DATE:	03/07/2022
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Eric So Hu, Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not provide adequate supervision to resident.
Resident suffered multiple falls while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Eric So Hu, Administrator and explained the reason for the visit.

On 07/03/2020, the Department received a complaint (#29-AS-20200703123416) alleging “Staff did not provide adequate supervision to resident” and “Resident suffered multiple falls while in care”. On 07/08/2020, at 3:29pm, Licensing Program Analyst (LPA) Mark Jeffries initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, the complaint investigation was conducted telephonically with House Manager, Laarni SoHu. LPA Jefferies interviewed Laarni SoHu and requested copies of pertinent documents relevant to the investigation.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

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-20200703123416

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: SUPERIOR RESIDENTIAL CARE FOR THE ELDERLY II	FACILITY NUMBER: 425801082
	VISIT DATE: 03/07/2022

NARRATIVE

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On 12/01/2021, from 4:04pm to 4:37pm, LPA Lyndia Sager conducted interviews with the Reporting Party; the Administrator, Eric SoHu, and requested additional documents relevant to the investigation; and on 12/23/21, at 4:08pm, with the Resident #1 (R1) Representative.

On the allegation: Staff did not provide adequate supervision to resident. It was alleged that R1 frequently leaves the facility unassisted and hitchhikes to the local liquor store. R1 has been observed to be under the influence of alcohol. LPA Sager reviewed R1’s Physician Reports dated 02/23/2015 and 11/30/2020 – both reports state a diagnosis of seizure disorder and mild cognitive impairment. Both reports indicate R1 is independent, has a history of alcohol use/abuse, and can leave the facility unassisted. Interviews with Administrator and R1’s representative indicate R1 is independent, has a history of alcohol use, and continues to choose to consume alcohol. Medication for alcohol abuse was not recommended by the doctor since R1 is not willing to quit alcohol use. Information obtained from the interviews also found that the Administrator is in communication with R1’s representative on an ongoing basis regarding R1’s care and condition. R1’s representative states they are happy with the care and supervision the facility provides to R1. A review of medical notes found that the Administrator takes R1 to medical appointments, including physical therapy, on a regular basis. A review of the staff schedule found that the facility has adequate staffing to care for 4 residents of which 3 out of 4 residents are independent. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Resident suffered multiple falls while in care. It was alleged that R1 suffered multiple falls and observed to have skinned/bloody knees due to falls. Per the Administrator, R1 uses a walker to assist with walking. When R1 has fallen, injuries have required first aid only. On 06/10/2020, R1 was referred to physical therapy for gait training and leg strengthening for multiple falls due to alcohol intake. Physical therapy was prescribed for R1 for the period 06/18/2020 through 09/15/2020 to improve gait and strength in legs. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview, copy of report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022

LIC9099 (FAS) - (06/04)

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