455001567-4-28-2022-25-AS-DLOA-CDX3ML-20220428182231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 455001567
Report Date: 04/28/2022
Date Signed: 04/28/2022 06:23:35 PM

Document Has Been Signed on 04/28/2022 06:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	A BRAND NEW DAY		FACILITY NUMBER:	455001567
ADMINISTRATOR:	TAYLOR, VERNA		FACILITY TYPE:	740
ADDRESS:	779 KERRY-JEN COURT		TELEPHONE:	(530) 223-1538
CITY:	REDDING	STATE: CA	ZIP CODE:	96002
CAPACITY:	26	CENSUS: 14	DATE:	04/28/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee Mary Burger, Administrator Sy Majid		TIME COMPLETED:	05:50 PM

NARRATIVE

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Community Care Licensing (CCL) Licensing Program Analysts (LPA) David Loperena, Jaclyn Avila, Misty Valencia, and Regional Manager (RM) Alycia Berryman arrived at the facility unannounced for a case management visit. Prior to entering the facility, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 Mask. LPAs Loperena, Avila, Valencia, and LPM Berryman were not screened by staff upon entering.

The purpose of the case management visit is to investigate unusual incident/injury report(s) (LIC 624) received by the Department.

On 4/22/22 an LIC 624 involving resident on resident violence was submitted via fax as required by regulation by the facility, whereupon Resident 1 (R1) struck Resident 2 (R2) first with a tissue box, and then with their fist that. This reported incident occurred on 04/20/2022 at 11:15 AM. According to the incident report, no substantial injury was sustained by either party. Later on 4/20/2022 at 3:35 PM, R1 entered Resident 3’s (R3) room and grabbed their shoulder, startling R3. R3 was not injured during the altercation, though according to the report, staff needed to stay with R3 until R3 calmed down.

CCL requested documents for R1 and R2 from facility administrator Sy Majid. CCL reviewed R1’s Physician's Report (LIC 602) dated 04/05/2022 and R1’s needs & services plan dated 11/10/2021. In both documents, R1 is documented as needing supervision due to aggressive behavior. R1’s needs and services plan explicitly states, “…requires extensive supervision due to their disruptive behaviors which include destruction of property, and aggression towards residents and staff.”

When asked about R1’s needs, the licensee stated that R1 is in need of a "sitter" and has requested this of the family. Although these behaviors have been identified the licensee as well as the need for increased staffing the licensee has failed to provided an adequate number of direct care staff to support each resident's safety as identified in the appraisal.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See 809D). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: David Loperena	TELEPHONE: (916) 204-5819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/28/2022 06:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: A BRAND NEW DAY	FACILITY NUMBER: 455001567
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/29/2022 Section Cited	1 2 3 4 5 6 7	87705(c)(4) Care of Persons with Dementia Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: There is an adequate number of direct care staff to support each resident's safety...as identified in their current appraisal.
	8 9 10 11 12 13 14	This requirement is not me as evidenced by: Based upon interview and document review, the licensee failed to ensure there was adequate number of direct care staff to ensure the safety of 2 of 2 residents in care. This poses an immediate Health, Safety to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: David Loperena	TELEPHONE: (916) 204-5819
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC809 (FAS) - (06/04)

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