486803359-9-30-2021-21-AS-HDBI-C7ZVAZ-20211021161647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803359
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:21:05 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2021 and conducted by Evaluator Karina Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210714122503

FACILITY NAME:	KELLYS FAMILY CARE		FACILITY NUMBER:	486803359
ADMINISTRATOR:	CUPID, ALMA V.		FACILITY TYPE:	735
ADDRESS:	392 TULIP STREET		TELEPHONE:	(707) 342-3701
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	6	CENSUS: 6	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Alma Cupid, Licensee & Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident's care needs are not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Karina Canela arrived at Kellys Family Care on 09/30/2021 for the purpose of delivering findings on complaint # 21-AS-20210714122503. LPA met with Alma Cupid, Licensee and Administrator.

LPA investigated the allegation of “Resident's care needs are not being met”. During the investigation, LPA conducted staff and resident interviews, reviewed the facility file, inspected the facility, obtained and reviewed records.

Report continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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-20210714122503

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: KELLYS FAMILY CARE	FACILITY NUMBER: 486803359
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/07/2021 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit a written plan on how Kelly's Family Care facility will ensure current and future client's care needs will be met. Written plan to be submitted to Community Care Licensing (CCL) by POC due date 10/07/2021
	8 9 10 11 12 13 14	Based on LPA's observation, interviews & record review, Licensee did not ensure the regulation above due to not following C1's Individual Program Plan as required. This is a potential risk to the Health & Safety of clients in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210714122503

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: KELLYS FAMILY CARE	FACILITY NUMBER: 486803359
	VISIT DATE: 09/30/2021

NARRATIVE

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Community Care Licensing (CCL) received a report alleging Client (C1)’s care needs were not being met due to C1 observed with unkept toenails. C1’s toenails were observed “outgrown and misshaped” and “developed toenail fungus”.
Interviews conducted revealed C1 is functionally capable of managing their Activities of Daily Living (ADLs), however, C1 requires prompting. C1’s Appraisal/Needs & Service Plan (CCL form LIC625), which is completed by Kelly’s Family Care facility, indicated in the Functional Skills section that the objective plan for C1 is “verbal prompting hygiene skills”. Additionally, C1’s North Bay Regional Center (NBRC) Individual Program Plan (IPP) with Person-Centered Objectives (dated 05/26/2021) was reviewed. C1’s IPP Objective #2 – Residential & Financial: Personal Care revealed C1 “requires reminders and/or assistance with ADL’s”, C1 “is prompt-dependent for tasks, needs supervision and reminders to ensure [C1] does a good job”, and “needs help to …trim nails”.
Interviews conducted revealed before the COVID-19 Pandemic, the plan for C1’s nail care was for C1’s family/responsible party to take C1 to the nail salon. During the pandemic, the plan for C1 was not an available option due to COVID-19 precautions and the temporary Stay at Home Order. Licensee stated the facility assumed C1 was cutting their own toenails since they observed a nail clipper in C1’s room and assumed the nail clipper was provided by C1’s responsible party. Licensee stated they did not observe C1’s overgrown nails since C1 had their socks and/or shoes on and the facility does not assist with showers. The Licensee stated if they would have known C1 was not clipping their own nails, they would have notified C1’s responsible party and NBRC Service Coordinator to address the issue. Licensee stated they did not notify C1’s responsible party or NBRC Service Coordinator and did not prompt C1 to clip their nails. Kelly’s Family Care facility staff stated they assumed C1 was managing their own nail care and as a result failed to prompt C1 as required in the IPP objective #2 section plan. Licensee scheduled and transported C1 to a podiatry appointment on 06/24/2021 once C1’s toenail concerns were brought to their attention.

Based on LPA’s observations, interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
California Code of Regulations, Title 22, Division 6 & Chapter 1, are being cited on the attached LIC 9099D.
Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Provided.
Exit interview conducted with Licensee Alma Cupid, whose signature below confirms receipt of report

Due to printer issues, LPA emailed a copy of this report and appeal rights to Licensee.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Karina Canela
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

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