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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002708
Report Date: 06/09/2021
Date Signed: 06/10/2021 04:56:34 PM



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
03/25/2021 and conducted by Evaluator Misty Valencia
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20210325123811
FACILITY NAME:LADY OF GRACE CARE FACILITYFACILITY NUMBER:
455002708
ADMINISTRATOR:MAYER, CELIA CFACILITY TYPE:
740
ADDRESS:277 EDINBURGH PLTELEPHONE:
(530) 226-1689
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 6DATE:
06/09/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Celia Mayer, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff will not allow resident to use the restroom
Staff left resident unattended on the toilet
Staff does not treat resident with respect
INVESTIGATION FINDINGS:
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On 6/10/2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegation and met with Administrator Celia Mayer. 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 and gloves. Additionally, LPA was screened by Administrator Celia Mayer. The purpose of the visit is to deliver the following complaint findings: Staff will not allow resident to use the restroom, Staff left resident unattended on the toilet, Staff does not treat resident with respect.

continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
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 5
Control Number 25-AS-20210325123811
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: LADY OF GRACE CARE FACILITY
FACILITY NUMBER: 455002708
VISIT DATE: 06/09/2021
NARRATIVE
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Staff will not allow resident to use the restroom
LPA interviewed facility staff, resident, and reviewed records. During the investigation, it was determined that there was insufficient evidence to substantiate staff will not allow resident to use the restroom. Interviews that were conducted concluded that staff and the resident all report R1 could use the restroom when needed. R1 denied restriction from using the restroom. R1 reported that there were times R1 had to wait a little while because staff was attending to another resident, but R1 was able to go.

Staff left resident unattended on the toilet
LPA interviewed facility staff, resident, and reviewed records. During the investigation, it was determined that there was insufficient evidence to substantiate staff left resident unattended on the toilet. Interviews that were conducted concluded that staff and the resident reported LPA that In order to afford R1’s privacy that is deserved while toileting, we would step outside the restroom and wait outside the door. When R1 was finished with toileting, R1 would either push the call button or say, “I’m done” and that’s when we come in and assist R1. R1 reported that they did request for privacy while in the restroom.

Staff does not treat resident with respect
LPA interviewed facility staff, resident, and reviewed records. During the investigation, it was determined that there was insufficient evidence to substantiate staff does not treat resident with respect. Interviews that were conducted concluded that staff and the resident all reported there was not any disrespect towards any of the residents. R1 reported that staff never yelled at R1. R1 stated that R1 just felt as if the staff did not like R1, due to using the restroom too many times.

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

An exit interview was conducted and a copy of this report, dated 06/10/2021 was provided.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
03/25/2021 and conducted by Evaluator Misty Valencia
COMPLAINT CONTROL NUMBER: 25-AS-20210325123811

FACILITY NAME:LADY OF GRACE CARE FACILITYFACILITY NUMBER:
455002708
ADMINISTRATOR:MAYER, CELIA CFACILITY TYPE:
740
ADDRESS:277 EDINBURGH PLTELEPHONE:
(530) 226-1689
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 6DATE:
06/09/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Celia Mayer, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff removed residents call button
INVESTIGATION FINDINGS:
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On 6/10/2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit regarding the above allegation and met with Administrator Celia Mayer. 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 and gloves. Additionally, LPA was screened by Administrator Celia Mayer. The purpose of the visit is to deliver the following complaint findings:Staff removed residents call button

continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20210325123811
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: LADY OF GRACE CARE FACILITY
FACILITY NUMBER: 455002708
VISIT DATE: 06/09/2021
NARRATIVE
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Staff removed residents call button

LPA interviewed facility staff, residents, and reviewed records. During the investigation, it was determined that there was sufficient evidence to substantiate that staff had removed the call button. During the investigation, the Admin admitted this it is true that she took away the call button, but it happened only one time. Admin reported that R1 had a habit of going to the restroom very, very frequently. At the time of the incident, R1 sat on the toilet and wanted to be returned to R1’s bedroom immediately without accomplishing anything. R1 asked us to take R1 back to the restroom a half hour later. I encouraged R1 to take the time and not rush. I then put the call button a foot away from her and told R1 I’d be outside waiting by the door to wait. When R1 expressed her displeasure at the call button being put away and we did not take the call button anymore. As a result of this investigation, LPA finds the allegation to be substantiated

Based on the findings of this investigation LPA finds allegations to be 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 observed and cited on the following LIC 9099-D pursuant to Title 22 rules and regulations, Health and Safety Codes, and Welfare and Institutions Code.

An exit interview was conducted and a copy of this report, dated 06/10/2021 was provided.

SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20210325123811
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: LADY OF GRACE CARE FACILITY
FACILITY NUMBER: 455002708
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/18/2021
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in all residential care facilities for the elderly shall have all of the following personal rights...To be free from punishment... this requirement is not met as evidenced by:
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Licensee agrees to submit a statement of understanding that residents are to receive assistance with needs identified in their appraisal needs and services plan
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Based on interviews and record review the Administer removed R1's emergency call button, which poses an immediate health and safety risk to residents in care.
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The statement will include that the licensee will submit a comprehensive plan for how the services will be provided to all current residents by 06/18/2021.
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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.
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5