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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002618
Report Date: 12/02/2022
Date Signed: 12/02/2022 03:09:32 PM

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
09/22/2022 and conducted by Evaluator Kevin Mknelly
COMPLAINT CONTROL NUMBER: 25-AS-20220922105537
FACILITY NAME:DE MOLL HOMEFACILITY NUMBER:
455002618
ADMINISTRATOR:VICTORINE, CHAYLENEFACILITY TYPE:
735
ADDRESS:1213 DE MOLL DRIVETELEPHONE:
(530) 410-9627
CITY:REDDINGSTATE: CAZIP CODE:
96002
CAPACITY:4CENSUS: 4DATE:
12/02/2022
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Chaylene VictorineTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff did not provide care and supervision needed for client to maintain a clean, safe and sanitary bedroom.

Licensee did not arrange repair of a roof leak timely.

Facility staff did not provide supervision to a client whose physician stated needed assistance in the community.
INVESTIGATION FINDINGS:
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On 12/2/22 , Licensing Program Analyst (LPA) Kevin Mknelly spoke with Chaylene Victorine, Administrator of facility De Moll Home, 455002618, by phone, at approximately 1:00 PM.
LPA was unable to meet at the facility due to current circumstances.

LPA reviewed resident records, facility records and conducted interviews by phone and email.
LPA finds that the allegations cited above are substantiated.

Facility staff did not provide care and supervision needed for client to maintain a clean, safe and sanitary bedroom. Report provided for services provided by an area Restoration company, on 3/7/22, provided extensive photographs of R1’s bedroom which was being cleared after R1 moved from the facility. Photographs showed R1s room to have several fish tanks with extensive algae growth, extensive clutter, dirty moldy surfaces on table-tops/ walls and floor, stained bed, left-over food on dishes and in containers, trash throughout the room, dirty laundry and supplement capsules and tabs on the floor and under the bed.
Report continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
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 4
Control Number 25-AS-20220922105537
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: DE MOLL HOME
FACILITY NUMBER: 455002618
VISIT DATE: 12/02/2022
NARRATIVE
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Facility staff did not provide supervision to a client whose physician stated needed assistance in the community. LPA reviewed R1’s Physician’s report dated 1/24/20. The report noted that R1 is not able to leave the facility unassisted.
Interviews and statements form FNRC and Administrator as well as note that R1 demonstrated skills and abilities to navigate in the community safely while alone. However, the licensee was either unaware of the physician’s assessment or chose to make their own determination without consultation and update from R1’s physician.
The licensee is responsible to follow 80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care.

Report reviewed with Chaylene Victorine . Copy of this report and appeal rights provided.
LPA requested return of signed copy after review.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 25-AS-20220922105537
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: DE MOLL HOME
FACILITY NUMBER: 455002618
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/30/2022
Section Cited
CCR
80068.3(b)
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Modifications to Needs and Services Plan (b) If the licensee determines that the client's needs cannot be met, the licensee shall inform the client, and his/her authorized representative, … This was not met based on records and interviews regarding R1's non-compliance to house rules. Potential risk to R1.
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Licensee will submit a statement of understanding of this requirement which outlines the procedures for reassessing, monitoring and addresing of client unmet needs, to CCL by the POC date of 12/30/22.
Type B
12/30/2022
Section Cited
CCR
80087(a)
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Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This was not met based on records, interviews and photos that R1's room was not sanitary.
Potential risk to client
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Licensee will submit a facility plan for monitoring and addressing the safe/sanitary conditions of the home, including client rooms and how issues will be addressed timely, by the POC date of 12/30/22
Type B
12/30/2022
Section Cited
CCR
80078(a)
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Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met based on records and interviews regarding unaccompanied outings. This possed a potential risk.
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Licensee will submit a plan for review of and update to, when needed, all client physician reports and care plans to ensure client needs are accurately identified and addressed, by the POC date of 12/30/22.
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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: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 25-AS-20220922105537
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: DE MOLL HOME
FACILITY NUMBER: 455002618
VISIT DATE: 12/02/2022
NARRATIVE
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** Amended** R1’s Physician’s report dated 1/24/20, notes R1 requires “ reminders” Prompts” “direction and redirection” for effective communication, to follow direction and perform self-care.
Consumer Confidential Information record dated Dec. 2021 notes, for R1” most times staff remind (R1) (do do laundry) because (they) will let it pile up until it smells throughout the house…as well as staff initiating (R1) clean (their) room… (R1 often refuses staff helping… (R1) stating (they has already done it but staff notice its not done in completion.
Far Northern Region Center (FNRC)personnel stated in a phone interview with LPA Mknelly that the licensee had been informed that they may request a relocation of R1 due to the failure to comply with/ allow for a clean and safe room. Accordingly, the licensee chose not to pursue that option.
As R1 was known by staff to be non-compliant to cleaning R1’s room or maintaining their fish tanks the licensee had a duty to follow CCR 80068.3 Modifications to Needs and Services Plan (b) If the licensee determines that the client's needs cannot be met, the licensee shall inform the client, and his/her authorized representative, … and request that the client relocate to a facility that can provide the needed services.

Licensee did not arrange repair of a known roof leak timely. Video provided to the Department by a witness showed water leaking through a whole in the ceiling of R1’s room. The video and date of the leak could not be confirmed by the LPA. However, a written statement provided by Administrator Chaylene Victorine stated, “On January 21st 2022 Friday 7:55pm they were informed about a supposed mold/leak issue In R1’s room. (it was the) first time hearing anything about a supposed leak or the potential for mold as (facility staff) were never allowed in R1’s room to clean or assist them."
Administrator notified LPA on 10/23/22 that room and roof repairs have been complete for the room vacant since R1’s move out in January 2022.
The licensee is responsible to follow 80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
SUPERVISORS NAME: Maribeth Senty
LICENSING EVALUATOR NAME: Kevin Mknelly
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4