455002730-2-27-2024-59-AS-KHOS-D39HNH-20240311062047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 455002730
Report Date: 02/27/2024
Date Signed: 02/27/2024 09:07:08 AM

Unsubstantiated

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
12/06/2023 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 59-AS-20231206081549

FACILITY NAME:	IPS- PICKFORD WAY		FACILITY NUMBER:	455002730
ADMINISTRATOR:	GARDNER, BONNIE		FACILITY TYPE:	735
ADDRESS:	20374 PICKFORD WAY		TELEPHONE:	(530) 605-3605
CITY:	REDDING	STATE: CA	ZIP CODE:	96003
CAPACITY:	4	CENSUS: 3	DATE:	02/27/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	STEPHEN WILLIS		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff does not ensure planned physical activities are offered to the clients in care.
Staff does not ensure clients are spoken to in an appropriate manner while in care.
Staff does not ensure reporting requirements are followed.

INVESTIGATION FINDINGS:

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On 02/27/24, Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 12/06/23. LPA Gurriere met with Stephen Willis, Administrator and explained the purpose of the visit.

Staff does not ensure planned physical activities are offered to the clients in care.

During the interview process, the administrator, five staff persons and one resident (Resident 1) were interviewed. Documents pertaining to the resident were collected and reviewed to include the resident’s Individual Program Plan, medications list, incident reports, and facility report log of incidents.

continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20231206081549

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: IPS- PICKFORD WAY	FACILITY NUMBER: 455002730
	VISIT DATE: 02/27/2024

NARRATIVE

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During the investigation process, it was reported that physical activities are offered to the resident and include walking around the block, walking inside the facility, going to the Sundial Bridge, going to the gym, basketball activity, stretching exercises, and public outings. In addition to the physical activities offered to the residents, the residents attend their Monday-Friday 9:00 a.m.- 2:00 p.m. day program, where activities are provided. Staff reported that sometimes the resident does not want to participate in physical activities as she uses a walker and sometimes a wheelchair.

Staff does not ensure clients are spoken to in an appropriate manner while in care.

During the interview process, the administrator, five staff persons and one resident (Resident 1) were interviewed. Documents pertaining to the resident were collected and reviewed to include the resident’s Individual Program Plan, medications list, incident reports, and facility report log of incidents.

During the investigation process staff reported that they do not use inappropriate language against the resident, nor have they heard their coworkers use inappropriate language. It was stated by several staff persons that the resident continually makes false allegations against the staff by stating that they use inappropriate name calling. The resident’s Individual Program Plan states “The resident has a history of making up allegations about peers and/or staff. Often these statements are targeted toward someone she does not like.”

Staff does not ensure reporting requirements are followed.

During the investigation process all staff reported that they complete a daily log of incidents that occur and that they write incident reports for management to submit to licensing and the regional center. The administrator advised that he does submit incident reports to licensing and the regional center. Several incident reports were submitted to the licensing agency regarding the behaviors of Resident 1.

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

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024

LIC9099 (FAS) - (06/04)

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