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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804114
Report Date: 10/04/2023
Date Signed: 10/04/2023 04:16:46 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, 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
06/06/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230606100758
FACILITY NAME:GOOD SAMARITAN CARE HOMEFACILITY NUMBER:
486804114
ADMINISTRATOR:DE GUZMAN, JANOLYN R.FACILITY TYPE:
740
ADDRESS:506 LABRADOR WAYTELEPHONE:
(650) 532-4317
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 3DATE:
10/04/2023
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Arinzana Reyes, House ManagerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility sustained a resident with prohibited condition
INVESTIGATION FINDINGS:
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On 10/4/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by House Manager, Arinzana Reyes. LPA toured the facility, reviewed resident records, interviewed staff and outside parties and made observations.
Complaint alleges facility sustained a resident with prohibited condition. Based on interviews with Licensee and staff (S1), it was stated that resident (R1) had sustained prohibited pressure injuries prior to the facility change of ownership on February 12, 2023. LPA conducted an interview with outside party (I1) also indicating that R1 sustained wounds prior to the new licensee taking control of the facility. Although both parties’ statements are consistent, there is no documentation indicating when R1’s wounds developed. The Licensee failed to properly seek appropriate emergency medical attention for R1 after observing wounds on R1’s heels on February 12, 2023. The Licensee notified Kaiser Vacaville Medical Center of the wounds, it was not until March 8, 2023 that R1 was assessed by Kaiser Vacaville and diagnosed with a stage 4 wound.

Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
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 5
Control Number 21-AS-20230606100758
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: GOOD SAMARITAN CARE HOME
FACILITY NUMBER: 486804114
VISIT DATE: 10/04/2023
NARRATIVE
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LPA conducted an interview with R1's Kaiser Hospice Nurse, (H1) who informed LPA that R1 was not receiving services from Kaiser prior to being placed on hospice and that H1 and Kaiser Vacaville did not have documentation indicating when R1's wounds developed. In addition, based on interview with former Licensee (I2) it was denied that R1 sustained wounds under I2’s care. The Licensee was contacted by telephone and reviewed report with LPA.

Allegation, facility sustained a resident with prohibited condition, is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Appeal Rights Given

Deficiency 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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/06/2023 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20230606100758

FACILITY NAME:GOOD SAMARITAN CARE HOMEFACILITY NUMBER:
486804114
ADMINISTRATOR:DE GUZMAN, JANOLYN R.FACILITY TYPE:
740
ADDRESS:506 LABRADOR WAYTELEPHONE:
(650) 532-4317
CITY:SUISUN CITYSTATE: CAZIP CODE:
94585
CAPACITY:6CENSUS: 2DATE:
10/04/2023
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Arinzana Reyes, House ManagerTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
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9
Neglect/lack of supervision
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 was greeted by House Manager, Arinzana Reyes. LPA toured the facility, reviewed resident records, interviewed staff and outside parties and made observations.
Complaint alleges facility neglect/lack of supervision leading to resident (R1) sustaining wounds. Based on interviews with Licensee and staff (S1), the facility did address and provide care for R1's wounds. It was found that on February 12, 2023, the Licensee observed wounds on R1's heels and notified Kaiser Vacaville. Administrator and staff provided care and supervision for R1 until R1 was assessed by Kaiser Vacaville. In the assessment R1 was diagnosed with a stage 4 wound and started hospice services. It is uncertain where and when the wounds developed into a stage 4, however the facility provided care and supervision for R1 during the time period of first observing R1's wounds to present. In addition, LPA Tobola interviewed outside party (I1) who stated that staff S1 and the Licensee have provided exceptional care for R1.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20230606100758
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: GOOD SAMARITAN CARE HOME
FACILITY NUMBER: 486804114
VISIT DATE: 10/04/2023
NARRATIVE
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Due to inconsistent information gathered and a lack of corroborating evidence indicating origins of R1's wounds, the allegation is found to be unsubstantiated. Allegation, neglect/lack of supervision 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 violation occurred. The Licensee was contacted by telephone and reviewed report with LPA. Appeal Rights Given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230606100758
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: GOOD SAMARITAN CARE HOME
FACILITY NUMBER: 486804114
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2023
Section Cited
CCR
87615(a)(1)
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87615(a)(1) Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:
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Licensee has followed appropriate measures to ensure R1 was placed under hospice services and provided wound care. Licensee understands requirements to seek immediate medical attention moving forward in cases of potential prohibited health conditions. Deficiency cleared at the time of visit.
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Based on record review and interviews with staff, Licensee and outside parties; Facility retatined a resident with a prohibited health condition after R1 was diagnosed with stage 4 wound. Facility was aware of wounds on 2/12/2023, but R1 was not assessed and diagnosed until 3/8/2023 which posed a potential health and safety risk to resident in care.
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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.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5