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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202713
Report Date: 10/19/2024
Date Signed: 10/19/2024 05:36:32 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20220404103902
FACILITY NAME:RACHELLE'S HOME IFACILITY NUMBER:
445202713
ADMINISTRATOR:RECINTO, RACHELLEFACILITY TYPE:
740
ADDRESS:99 AIRPORT BLVDTELEPHONE:
(831) 319-4190
CITY:FREEDOMSTATE: CAZIP CODE:
95019
CAPACITY:12CENSUS: 9DATE:
10/19/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Magali EsquivelTIME COMPLETED:
04:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not administer prescribed medications to resident resulting in resident suffering pain.
Facility did not notify hospice agency of resident's change in condition
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/19/2024, LPA Johnson arrived unannounced to deliver findings for the above allegations. LPA met with Magali and later joined by Alquin Gamab.

Based on records review and interviews with current staff the department was unable to determine if R1 suffered as a result of the facility neglecting to notify the hospice agency about a change in condition. The alleged lack of notification could have contributed to R1 having trouble with pain referred to in this complaint. If there was discomfort or pain it could have been addressed by the hospice agency.

The department could not confirm that the hospice agency was notified of the R1's change in condition, nor could the department from the review of records identify that R1 had a change of condition that would have warrant a call to the hospice agency. R1's condition on discharge from the skilled nursing facility to this care home on hospice was unmanaged right hip pain.

The above allegations are unsubstantiated
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
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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