<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803359
Report Date: 11/16/2021
Date Signed: 11/16/2021 12:11:08 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, 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
10/14/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20211014093428
FACILITY NAME:KELLYS FAMILY CAREFACILITY NUMBER:
486803359
ADMINISTRATOR:CUPID, ALMA V.FACILITY TYPE:
735
ADDRESS:392 TULIP STREETTELEPHONE:
(707) 342-3701
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alma CupidTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries while in care
Residents clothes were dirty
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Alma Cupid to discussed the findings. During the course of this investigation statements were taken from witnesses and staff; records were obtained and reviewed; site visits made to facility and collateral program. The following determinations are made: C1 sustained several scratches on body while at the facility; Staff have not provided an explanation for the origin of the injuries; C1 has stated to witnesses that the scratches were self inflicted. There are differing opinions regarding the cleanliness clothing of C1; Case Manager for C1 reports that C1's clothing was not found to be dirty during the course of unannounced quarterly visits to the facility. Although the allegations may be true or valid, based on records and statements, the preponderance of evidence standard has not been met. Therefore, the allegations are UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 3
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
10/14/2021 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20211014093428

FACILITY NAME:KELLYS FAMILY CAREFACILITY NUMBER:
486803359
ADMINISTRATOR:CUPID, ALMA V.FACILITY TYPE:
735
ADDRESS:392 TULIP STREETTELEPHONE:
(707) 342-3701
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:6CENSUS: 5DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Alma CupidTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not administer resident's medication
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Alma Cupid and discussed the findings. C1 has a long standing prescription for dental rinse which is to be administered twice a day. During the course of this investigation, statements were taken, records reviewed, site visits made to facility and collateral program. The following determinations have been made: Licensee states that the rinse was administered twice a day as ordered; Staff responsible for PM medication pass states that C1 was not administered pm dose of rinse; C1's relative states that C1's dentist opined that the rinse is not being sufficiently utilized; C1 has made ambivalent statements regarding the frequency of use of the rinse; C1 left the facility for another placement with a half empty bottle of mouth rinse and the label indicated it was filled on 4/29/2019. Based upon the statements made, records and photographs reviewed, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given. Exit interview.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 3
Control Number 21-AS-20211014093428
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: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2021
Section Cited
CCR
80075(b)(5)(B)
1
2
3
4
5
6
7
Health Related Services. Once ordered by the physician the medication is given according to the physician's directions. Based upon statements taken from witnesses and staff, this requirement has not been met as evidenced by: Medication for C1 was not administered twice daily as ordered on occasions in the past.
1
2
3
4
5
6
7
Administrator to review the requirements of 80075 and will submit a dated and signed declaration to verify the review. Declaration to be submitted by POC date in order to clear the deficiency.
8
9
10
11
12
13
14
 This posed a potential risk to the health of C1
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: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3