486804052-7-13-2023-21-AS-HDBI-CTQTNE-20230714145238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804052
Report Date: 07/13/2023
Date Signed: 07/13/2023 10:42:48 AM

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
05/18/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230518145452

FACILITY NAME:	C & R CARE HOME LLC		FACILITY NUMBER:	486804052
ADMINISTRATOR:	BAYOT, ROBERT CHRISTIAN		FACILITY TYPE:	740
ADDRESS:	373 HERON WAY		TELEPHONE:	(510) 789-5155
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95688
CAPACITY:	5	CENSUS: 3	DATE:	07/13/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Caregivers, Adrew Baybay and Cristina Bayot		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Neglect/lack of supervision resulted in death.
Staff did not administer resident’s medications as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs), Farhaan Sarangi and Carol Fowler arrived unannounced at C & R Care Home LLC for the purpose of opening a complaint. LPA was greeted at the door by Caregiver, Adrew Baybay, and was granted access into the home. Facility Manager, Cristina Bayot arrived 30 minutes later.

During the course of the investigation, LPA reviewed resident(s) records, facility records, interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses.

Complaint alleges Neglect/lack of supervision resulted in death. Based on documents that were reviewed, LPA learned that the resident was on a Special Diet as outlined in resident records that were reviewed. In addition, interviews with outside providers, witnesses, and the Designated Power of Attorney (DPOA) revealed no concerns with the quality of care that the facility provided during the time the resident was at the facility. Facility followed the Hospice Plan of Care for the resident in placement. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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-20230518145452

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: C & R CARE HOME LLC	FACILITY NUMBER: 486804052
	VISIT DATE: 07/13/2023

NARRATIVE

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Complaint alleges that Staff did not administer resident’s medication as prescribed. Based on interviews that were conducted, LPA learned that the facility was following the Hospice Care Plan and the Medication Orders as prescribed by the Doctor. Furthermore, A review of the Medication Assessment Record (MAR) revealed that the facility followed prescribing methods and orders by the Physician and that there were no changes to the medication by the physician.

A finding that the complaint allegations of Neglect/lack of supervision resulted in death and Staff did not administer resident’s medications as prescribed are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed and given to the Caregiver, Cristina Bayot.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC9099 (FAS) - (06/04)

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