425850004-4-16-2021-29-AS-KBUY-C2BTRA-20210422145713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850004
Report Date: 04/16/2021
Date Signed: 04/16/2021 03:40:53 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
07/20/2020 and conducted by Evaluator Arien Diaz

COMPLAINT CONTROL NUMBER: 29-AS-20200720120900

FACILITY NAME:	YOKAM'S RCFE #1		FACILITY NUMBER:	425850004
ADMINISTRATOR:	KAMTO, YOLANDE KONGUEP T.		FACILITY TYPE:	740
ADDRESS:	958 E TUNNELL ST		TELEPHONE:	(805) 922-7670
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93454
CAPACITY:	6	CENSUS: 5	DATE:	04/16/2021
		UNANNOUNCED	TIME BEGAN:	03:25 PM
MET WITH:	Alphonse Kamto		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Questionable death of resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Diaz conducted a subsequent complaint visit to deliver final findings of the complaint investigation. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, LPA Diaz met on a telephonic video with Alphonse Kamto.

On the allegation: Questionable death of resident in care. LPA Diaz reviewed facility documents and conducted interviews with staff and attempted to interview 4 residents. LPA interviewed staff on 09/24/2020 at 4:00pm, 4:18pm, and 4:36pm and on 09/25/2020 at 11:03am. All staff interviewed stated that Resident 1 (R1) struggled with pain in their entire body, was weak, showed difficulties breathing and had bowel movement issues. All staff interviewed stated that R1 was usually agitated and upset. All staff members stated that they consistently provided care and services to R1. LPA interviewed residents on 9/25/2020 at 3:10pm, 3:22pm, and 3:30pm. 2 of 3 residents had not known R1 when R1 lived at the facility. 1 of 3 residents stated that R1 was always unsatisfied with the services in the facility and yelled at the staff.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

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-20200720120900

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: YOKAM'S RCFE #1	FACILITY NUMBER: 425850004
	VISIT DATE: 04/16/2021

NARRATIVE

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All residents interviewed stated that they have no problems with the staff, and that the staff always fulfills their requests and necessary services, and their needs are met. Residents interviewed also stated that the facility has two especially good caregivers, but all caregivers treat residents well. On 04/09/2021 and 04/11/2021, LPA reviewed hospice records and notes for R1. The records indicate that R1 had been on hospice since September 2019. The records also illustrate communication between R1’s family and a credible source. The records revealed that R1’s family wanted R1 to stay in the facility. The records revealed R1’s family believed R1 was frustrated due to R1’s physical condition, and the family decided to provide a private caregiver for nighttime. In the records, R1’s family member described the licensee and staff as patient and kind. Interviews with a credible source revealed in their opinion, R1 received adequate care to meet R1’s needs. R1’s diagnoses were heart failure and spinal stenosis, and R1 used oxygen. On 7/19/2020, R1 passed away and the cause of death was listed as end stage cardiovascular disease. Based on the evidence gathered through interviews and records reviewed, the allegation is deemed unsubstantiated at this time.

Exit interview, report given via email.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 04/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2021

LIC9099 (FAS) - (06/04)

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