486800076-9-20-2023-21-AS-KMOA-CW3VMF-20230927163328

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486800076
Report Date: 09/20/2023
Date Signed: 09/20/2023 04:10:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20230710113429

FACILITY NAME:	GRIFFIN FAMILY CARE HOME - FIELDSTONE		FACILITY NUMBER:	486800076
ADMINISTRATOR:	BRENDA SHERIDAN		FACILITY TYPE:	735
ADDRESS:	215 FIELDSTONE COURT		TELEPHONE:	(707) 554-1050
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	6	CENSUS: 4	DATE:	09/20/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Ana Rodriguez, Lead Staff		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff failed to seek timely medical treatment for client in care

INVESTIGATION FINDINGS:

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On 9/20/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and a was greeted by Lead Staff, Ana Rodriguez. LPA and the department toured the facility, interviewed staff, clients and outside parties, reviewed resident and facility records and made observations.

Complaint alleges staff failed to seek timely medical treatment for client in care regarding client (C1) requiring medical attention for observed wounds on the wrist and complaints of back pain. Based on review of facility records and client C1 chart notes, it was found that on 6/25/2023, C1 was discharged from the hospital and prescribed with multiple medications for back pain. On 7/1/2023, C1 had complained of back pain due to injury resulting in C1 provided appropriate medications. On 7/4/2023, C1 spoke with an outside party/relative with C1 wanting to be taken to the hospital. C1 chart notes indicate that C1 was scheduled for a phone visit with their primary care provider on 7/5/2023 and resulted in a physical medical assessment scheduled the following day on 7/6/2023. Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

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 21-AS-20230710113429

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GRIFFIN FAMILY CARE HOME - FIELDSTONE	FACILITY NUMBER: 486800076
	VISIT DATE: 09/20/2023

NARRATIVE

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In addition, C1 was observed by staff to have sores on C1's wrists. C1 was found to have documented behavior of self-inflicting skin picking. On 6/25/2023 C1 was sent to the hospital for complaint of back pain. On the morning of 6/26/2023, staff S1 had observed C1 with sores on their wrists with photos taken. S1 indicated that C1 was wearing bracelets that C1 received as birthday gifts and was wearing a medical wristband; both of which may have caused C1 to have irritation and demonstrate self skin picking. On 6/28/2023, facility staff observed C1 to have picked their sores more severely and was sent out for medical attention two days after initial sores were observed. Due to a lack of corroborating evidence to determine when the sores began developing, the allegation is found to be unsubstantiated. Allegation, Staff failed to seek timely medical treatment for client in care is 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 violations occurred. Appeal Rights given.

No deficiencies cited during today's visit.

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023

LIC9099 (FAS) - (06/04)

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