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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 471372608
Report Date: 11/15/2023
Date Signed: 11/15/2023 04:59:35 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
11/07/2023 and conducted by Evaluator Sarah Benson
COMPLAINT CONTROL NUMBER: 59-AS-20231107164442
FACILITY NAME:BARKERS RESIDENTIAL CAREFACILITY NUMBER:
471372608
ADMINISTRATOR:DAUSEL, CYNDIFACILITY TYPE:
735
ADDRESS:200 4TH STREETTELEPHONE:
(530) 905-1409
CITY:MONTAGUESTATE: CAZIP CODE:
96064
CAPACITY:15CENSUS: 12DATE:
11/15/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:David Small and Erykah Timberlake-SmallTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility is dirty and has pests.
Staff do not ensure that residents in care are able to make and receive confidential phone calls.
INVESTIGATION FINDINGS:
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11/15/2023 1:00 PM Licensing Program Analysts (LPA) Sarah Benson made an unannounced visit to the facility and met with Administrator Erykah Timberlake-Small and David Small. The purpose of this visit was to open a complaint investigation.

LPA interviewed the administrator, 1 staff and 7 clients during the visit. LPA requested the following documents during the visit, admission agreements, physician reports and medical records.

The following deficiencies were observed (See LIC 9099D) and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, a copy of the report, and appeal rights provided.to administrator


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
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 2
Control Number 59-AS-20231107164442
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: BARKERS RESIDENTIAL CARE
FACILITY NUMBER: 471372608
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2023
Section Cited
CCR
80087(a)(1)
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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients... (1) The licensee shall take measures to keep the facility free of flies and other insects.
This requirement is not met as evidenced by:

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Put up fly strips
Create a cleaning check list.
Resident chore chart.
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Based on LPA observation the licensee did not clean the facility and at least 6 flies were in kitchen area.
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Due date 11-25-23
Type B
11/15/2023
Section Cited
CCR
85072(a)(9)
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To have access to telephones in order to make and receive confidential calls, provided that such calls do not infringe upon the rights of other clients and do not restrict availability of the telephone during emergencies.
This requirement is not met as evidenced by:
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Will get a land line or house cell phone.
Licensee will send a picture of phone and call LPA with new phone number.
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Based on LPA observation and client interviews the facility has no telephone on site.
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Due date 11-25-23
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: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2