455000981-4-5-2021-25-AS-RLBN-BZZUUG-20210412155328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455000981
Report Date: 04/05/2021
Date Signed: 04/05/2021 04:31:07 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2020 and conducted by Evaluator Pheej Cheng

COMPLAINT CONTROL NUMBER: 25-AS-20201014091131

FACILITY NAME:	JIM & LIZA'S CARE HOME		FACILITY NUMBER:	455000981
ADMINISTRATOR:	HOLDEN, MERLINDA		FACILITY TYPE:	740
ADDRESS:	4929 HUNTINGTON DRIVE		TELEPHONE:	(530) 221-0220
CITY:	REDDING	STATE: CA	ZIP CODE:	96002
CAPACITY:	6	CENSUS: 5	DATE:	04/05/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Merlinda Holden; Licensee		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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1) Resident fell while in care sustaining injuries
2) Staff mismanaging residents medication
3) Residents room is not free from dust
4) Staff not providng adequate food service
5) Residents had access to hazardous chemicals
6) Staff not meeting residents needs
7) Residents shower in disrepair
8) Staff making inappropriate comments towards resident

INVESTIGATION FINDINGS:

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On 4/5/21 at 2:30 PM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint investigations visit via telephone regarding the above allegations. A televisit was made in compliance to the department's procedures regarding COVID-19. LPA met with Administrator/Licensee Merlinda Holden.

Continuation on LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

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 4

Control Number 25-AS-20201014091131

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: JIM & LIZA'S CARE HOME	FACILITY NUMBER: 455000981
	VISIT DATE: 04/05/2021

NARRATIVE

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4) Staff not providing adequate food service

LPA determined that there is insufficient information available. All interviews with staff and residents indicate that meals provided are well-balanced and nutritious. Residents interviewed indicated that they do not have a special diet and have no complaints regarding the meals provided. Staff confirmed that they were aware of R1 being on a low residue diet and documents obtained show that the facility was aware of the diet along with what needs to be served.

5) Residents had access to hazardous chemicals.

LPA determined that there is insufficient information available. RP provided a picture of facility’s laundry room door being opened; however, there is a locked cabinet within the laundry room where all cleaning and hazardous material are stored. During LPA’s unannounced virtual tour on 3/13/21, LPA observed the cabinets to be locked and only accessible with a key. LPA also observed that there were no accessible hazardous and/or cleaning materials. Staff and resident statements confirmed that residents do not have access to any cleaning or hazardous materials and that those materials are kept in a locked cabinet in the laundry room.

6) Staff not meeting residents needs.

LPA determined that there is insufficient information available. Staff statements indicated that all residents are checked on frequently throughout the day; some more than others due to their condition. All staff stated that they were ware of R1 having bowel movements and required more attention and changing of R1’s diapers. This was confirmed by R5 who stated to have remember R1. R5 stated that R1 was having bowel movement issues and staff would always be in R1’s room to change her.

Continuation on LIC 9099C.

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20201014091131

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: JIM & LIZA'S CARE HOME	FACILITY NUMBER: 455000981
	VISIT DATE: 04/05/2021

NARRATIVE

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1) Resident fell while in care sustaining injuries

LPA determined that there is insufficient information available. All statements and documents obtained indicated that there were no incidents regarding R1’s fall in the bathroom; however, there was one document incident regarding R1’s fall in R1’s room. According to statements and incident reports obtained, R1 was assessed quickly and local fire department was called for assistance in transferring R1 from the ground to the bed. Medical attention was provided in a timely manner.

2) Staff mismanaging residents medication.

LPA determined that there is insufficient information available. Facility documents and statements indicate that R1’s PRN and prescribed medication were administered accordingly to doctor’s order. Statements from staff and residents indicate that staff member do observe residents take their medications.

3) Residents room is not free from dust

LPA determined that there is insufficient information available. RP provided pictures of R1’s room when R1 was being permanently moving out from the facility and it displayed R1’s fan being covered in dust and R1’s bedroom floor to be covered in debris. LPA Cheng conducted and unannounced virtual visit on 3/13/21 and observed all resident rooms and fans to be clean. LPA conferred with Licensing Program Manager Rayna Bryson and concluded that although the room might have been uncleaned at the time the pictures were taken, residents’ rooms are clean now, and remains cleans along with no complaints from current residents.

Continuation on LIC 9099C.

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20201014091131

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: JIM & LIZA'S CARE HOME	FACILITY NUMBER: 455000981
	VISIT DATE: 04/05/2021

NARRATIVE

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7) Residents shower in disrepair.

LPA determined that there is insufficient information available. During LPA’s unannounced virtual visit on 3/13/21, LPA requested for S1 to measure facility’s bathroom hot water temperature. LPA observed the thermometer reading to be 112 degrees Fahrenheit. Statements from residents indicate that they have never received a cold bath/shower and have no issues with the facility bathroom hot water temperature.

8) Staff making inappropriate comments towards resident.

LPA determined that there is insufficient information available. All staff and resident statements indicate that they have not seen or heard of any incidents regarding staff yelling at residents. All staff and residents interviewed denied any claims of staff making inappropriate comments towards R1.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Two copies of report provided and LPA requested for a signed copy to be returned.

SUPERVISORS NAME: Rayna L Bryson
LICENSING EVALUATOR NAME: Pheej Cheng
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC9099 (FAS) - (06/04)

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