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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002333
Report Date: 06/21/2023
Date Signed: 06/21/2023 10:52:07 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2023 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20230117154145
FACILITY NAME:PLATINUM HOMEFACILITY NUMBER:
455002333
ADMINISTRATOR:ZUMKEHR, ERICFACILITY TYPE:
735
ADDRESS:7279 PLATINUM WAYTELEPHONE:
(530) 247-0852
CITY:REDDINGSTATE: CAZIP CODE:
96001
CAPACITY:3CENSUS: 3DATE:
06/21/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Donovan LesherTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is not providing a comfortable mattress for resident
INVESTIGATION FINDINGS:
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LPA Hiratsuka conducted this unannounced complaint visit to deliver the findings. LPA spoke to Administrator Cameron Olson on the phone during this visit to explain the findings.

LPA investigated the allegation, "Facility is not providing a comfortable mattress for resident." LPA interviewed staff, a witness, and reviewed records.

The resident broke the bed that they were using. The administrator and another agency were working to find an bed suitable for the needs of the resident and was having an issue of who was responsible for paying the for the bed. In the meantime the resident was sleeping on a mattress on the floor. Title 22 regulations requires a facility to provide a bed for the resident unless the resident indicates they want to sleep on the floor. The resident has since been provided a bed. The administrator was in contact with the second agency that works with the resident as well as his management team about the issue with the bed, but forgot to contact Community Care Licensing Division (CCLD) about the issue to discuss alternative plans while waiting for the bed to be purchased.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
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
Control Number 25-AS-20230117154145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: PLATINUM HOME
FACILITY NUMBER: 455002333
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2023
Section Cited
CCR
85088(c)(1)
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Fixtures, Furniture, Equipment and Supplies. The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. An individual bed, except that couples shall be allowed to share one double or larger sized
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Licensee shall come up with a written plan of correction on how they shall ensure the residents have a bed to sleep on and if something breaks and it appears it will take some time to replace, who the Licensee shall contact to discuss the issue.
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bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s). Licensee failed this based on the resident not having a bed and was sleeping on a mattresss on the floor. This does not pose an immediate risk to the resident.
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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: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20230117154145
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: PLATINUM HOME
FACILITY NUMBER: 455002333
VISIT DATE: 06/21/2023
NARRATIVE
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Based on the above, the allegation is substantiated.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code. Failure to correct shall result in civil penalties. appeal rights left.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5