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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 471372608
Report Date: 02/14/2024
Date Signed: 02/14/2024 03:08:21 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: 11DATE:
02/14/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Erykah Timberlake-Small House ManagerTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff do not ensure that resident's medical and dental needs are being met while in care.
INVESTIGATION FINDINGS:
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2/14/2024 1:30 PM Licensing Program Analysts (LPA) Sarah Benson made an unannounced visit to the facility and met with Administrator Erykah Timberlake-Small to deliver final findings regarding a complaint that was received on 11/07/23.

LPA interviewed the administrator, 1 staff and 7 client 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: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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 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: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
85075(b)
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The facility shall develop and implement a plan which ensures that assistance is provided to the clients in meeting their medical and dental needs.
This requirement is not met as evidenced by:

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The administrator agrees to submit email or fax to the LPA a statement of how this type of deficiency will be avoided in the future. In addition, a copy of the plan for keeping medical and dental documents and appointments shall be emailed or faxed to the LPA.
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 Based on record review, interviews of staff persons and residents, the licensee did not implement a plan to ensure the assistance needed to meet all the medical and dental needs of residents in care.
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 Administrator shall advise the licensing agency the names of residents that need to see the doctor and or dentist and when that will be accomplished.
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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: Sarah Benson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2