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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002996
Report Date: 10/08/2024
Date Signed: 10/08/2024 12:18:53 PM

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
08/02/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20240802130610
FACILITY NAME:ANDERSON CREEK SRFFACILITY NUMBER:
455002996
ADMINISTRATOR:EZEANI, IFEANYIFACILITY TYPE:
772
ADDRESS:1901 BARNEY ROADTELEPHONE:
(916) 870-9676
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:14CENSUS: 5DATE:
10/08/2024
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:TIA THRUSHTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility allowed an adult to provide care and supervision to residents in care without fingerprint clearance.
Staff member raises voice and belittles residents in care.
INVESTIGATION FINDINGS:
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On 10/08/24 Donna Gurriere, Licensing Program Analyst (LPA) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 08/02/24. LPA Gurriere met with Tia Thrush, Administrator, and explained the purpose of the visit.


Facility allowed an adult to provide care and supervision to residents in care without fingerprint clearance.

During the interview process, the administrator, and nine staff persons were interviewed. In addition, Client documents were received and reviewed to include residents daily input log, staff persons personnel files, the employee Guardian roster and the Staff Person’s (Staff 1) Exemption Approval dated 06/14/24.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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 59-AS-20240802130610
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: ANDERSON CREEK SRF
FACILITY NUMBER: 455002996
VISIT DATE: 10/08/2024
NARRATIVE
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During the investigation process, it was reported that the staff person began employment in 12/2024 and ended his employment in 06/2024. It was stated by the administrator that the staff person “shadowed” other staff persons for six months. The administrator was advised that a staff person cannot shadow another staff person or work in a facility without a criminal record clearance, per the regulations.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

An immediate civil penalty in the amount of $500.00 is to be assessed for staff person not having a fingerprint clearance.

Staff member raises voice and belittles residents in care.



During the interview process, the administrator, and nine staff persons were interviewed. In addition, Client documents were received and reviewed to include residents daily input log, staff persons personnel files, the employee Guardian roster, and the staff person (Staff 1) Exemption Approval dated 06/14/24.

During the investigation process, staff were interviewed and reported that Staff 1 did raise his voice, did belittle the residents, gave inappropriate facial expressions, chased after residents, pointed his finger at residents, and was hostile towards them. It was reported that the residents were upset by the way that the staff person was treating them.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations, (Title 22), is cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date, civil penalties may be assessed.

SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 59-AS-20240802130610
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: ANDERSON CREEK SRF
FACILITY NUMBER: 455002996
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2024
Section Cited
CCR
81054(b)
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Notwithstanding Section 81054(a) above, an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code section 1522(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance, or requested and be approved for a transfer of an exemption as specified in Section 81019(e) prior to working, residing or volunteering in the facility.
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The administrator agrees to not allow staff persons to work or shadow another staff person without have the appropriate fingerprint clearance. The administrator agrees to submit a letter to the licensing agency advising that he will follow the regulation.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the administrator did not ensure that a fingerprint clearance was obtained regarding a staff person.
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Civil penalties will be assessed in the amount of $500.00.
Type A
10/09/2024
Section Cited
CCR
81072(a)(3)
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Personal Rights - Each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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The administrator agrees to provide training to all staff regarding the Personal Rights of residents that are residing in the facility. The administrator agrees to submit to the licensing agency a list of staff persons names and their signatures indicating that they have received the training.
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This requirement was not met as evidenced by: Based on interviews and records reviewed, the administrator did not ensure that the residents that were residing at the facility were given Personal Rights.
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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: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
08/02/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 59-AS-20240802130610

FACILITY NAME:ANDERSON CREEK SRFFACILITY NUMBER:
455002996
ADMINISTRATOR:EZEANI, IFEANYIFACILITY TYPE:
772
ADDRESS:1901 BARNEY ROADTELEPHONE:
(916) 870-9676
CITY:ANDERSONSTATE: CAZIP CODE:
96007
CAPACITY:14CENSUS: DATE:
10/08/2024
UNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:TIME COMPLETED:
12:25 PM
ALLEGATION(S):
1
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9
Staff does not ensure resident’s health condition is being properly addressed.
INVESTIGATION FINDINGS:
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During the interview process, the administrator, and nine staff persons were interviewed. In addition, Client documents were received and reviewed to include residents daily input log, staff persons personnel files, the employee Guardian roster, and the staff person (Staff 1) Exemption Approval dated 06/14/24.

During the investigation process, staff were interviewed and reported overall that the resident did have some falls and that the nurse would conduct an assessment and if the resident didn't have any injuries, they would not send him for medical treatment. It was stated that sometimes the resident refuses treatment; however, not for anything serious or needing medical treatment.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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 4