<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002046
Report Date: 05/12/2022
Date Signed: 05/13/2022 09:29:08 AM

Substantiated


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
01/21/2022 and conducted by Evaluator Misty Valencia
COMPLAINT CONTROL NUMBER: 25-AS-20220121154444
FACILITY NAME:PEREGRINE HOMEFACILITY NUMBER:
455002046
ADMINISTRATOR:BRANSCOMB, KALEBFACILITY TYPE:
735
ADDRESS:1163 PEREGRINE WAYTELEPHONE:
(530) 262-0967
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: 4DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Kaleb Branscomb, AdministatoTIME COMPLETED:
02:36 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair.
Facility has mold.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/12/2022, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegations and met with Kaleb Branscomb, Administator (admin). Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened at the front door.

continued on 9099-C


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
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 5
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
01/21/2022 and conducted by Evaluator Misty Valencia
COMPLAINT CONTROL NUMBER: 25-AS-20220121154444

FACILITY NAME:PEREGRINE HOMEFACILITY NUMBER:
455002046
ADMINISTRATOR:BRANSCOMB, KALEBFACILITY TYPE:
735
ADDRESS:1163 PEREGRINE WAYTELEPHONE:
(530) 262-0967
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:4CENSUS: DATE:
05/12/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:KalebTIME COMPLETED:
02:36 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not assist the resident's with toileting.
Residents are left in soiled diapers/liens for extended periods of time.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/12/2022, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegations and met with Kaleb Branscomb, Administator (admin). Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened at the front door.

continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20220121154444
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: PEREGRINE HOME
FACILITY NUMBER: 455002046
VISIT DATE: 05/12/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff do not assist the resident's with toileting.
Residents are left in soiled diapers/liens for extended periods of time.


During interviews with Administrator, staff, one out of four (1/4) Clients, and records reviewed, it was determined that Staff do not assist the resident's with toileting and
clients are left in soiled diapers/liens for extended periods of time to be Un-substantiated.
During the interview process it was reported that staff supervise residents twenty-four (24) hours a day and check on residents every hour during the night while clientss are sleeping. It was reported that staff are conscience of keeping the residents clean and dry. LPA toured the facility and facility appeared to be clean sanitary and free from odors. LPA did not observe any dirty diapers or smell of urine/feces. Allegation is Unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred and the findings are Unsubstantiated.

Exit interview conducted and copy of report given to administrator.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20220121154444
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: PEREGRINE HOME
FACILITY NUMBER: 455002046
VISIT DATE: 05/12/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility is in disrepair.
Facility has mold

During interviews with Administrator, staff, one out of four (1/4) Clients, and records reviewed, it was determined that the Facility is in disrepair and Facility has mold to be Substantiated. LPA observed facility to be currently under construction. Facility’s kitchen is taped off and facility still waiting on cabinets to come in. LPA received multiple documents/receipts regarding; rain/gutter/roof repair, kitchen/cabinet repair and mold repair. Therefore, the allegations are substantiated.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the allegation is found to be Substantiated. California Code of Regulations (Title 22) is being cited on the attached LIC 9099D. Appeal rights are provided, and a closure interview was conducted.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20220121154444
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: PEREGRINE HOME
FACILITY NUMBER: 455002046
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
80087(a)
1
2
3
4
5
6
7
Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times.This requirement was not met was evidence by. LPA observed the mold and facility in dis-repair. This poses a potential health and safety issue.
1
2
3
4
5
6
7
Plan of Correction; The facility is currenlty under construction. Lisensee agrees to keep LPA informed and update LPA with all updates.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Misty Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5