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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455000981
Report Date: 04/05/2021
Date Signed: 04/05/2021 03:43:46 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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-20201014091914
FACILITY NAME:JIM & LIZA'S CARE HOMEFACILITY NUMBER:
455000981
ADMINISTRATOR:HOLDEN, MERLINDAFACILITY TYPE:
740
ADDRESS:4929 HUNTINGTON DRIVETELEPHONE:
(530) 221-0220
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:6CENSUS: 5DATE:
04/05/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Merlinda Holden; LicenseeTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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1) Staff administered too much medication to the resident causing an overdose.
2) Staff are not following the resident's special diet.
3) Staff cannot communicate with the residents.
INVESTIGATION FINDINGS:
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On 4/5/21 at 2PM, 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.

1) Staff administered too much medication to the resident causing an overdose.

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. SN1 was unable to produce any documentations or additional information regarding the above allegation.
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 2
Control Number 25-AS-20201014091914
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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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2) Staff are not following the resident's special diet.

LPA determined that there is insufficient information available. All interviews with staff and residents indicated 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. LPA observed that facility had sufficient supply of foods and all foods observed were nutritious.

3) Staff cannot communicate with the residents.



LPA determined that there is insufficient information available. During LPA’s interview of staff members and residents, staff members were able to understand and respond back to LPA without any issues. Residents stated that they have no issues communicating with staff members. Staff members are of Filipino descent and do have an accent; however, that does not prove to be an issue with communicating with their residents.

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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