486804114-11-30-2023-21-AS-KMOA-CYA2HU-20231206162520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804114
Report Date: 11/30/2023
Date Signed: 11/30/2023 05:58:15 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
08/28/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20230828110508

FACILITY NAME:	GOOD SAMARITAN CARE HOME		FACILITY NUMBER:	486804114
ADMINISTRATOR:	DE GUZMAN, JANOLYN R.		FACILITY TYPE:	740
ADDRESS:	506 LABRADOR WAY		TELEPHONE:	(650) 532-4317
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 3	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	01:47 PM
MET WITH:	Leonida Arinzana, Lead Staff		TIME COMPLETED:	06:10 PM

ALLEGATION(S):

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Staff do not ensure resident records are properly maintained
Licensee does not ensure staff are in good physical, mental health to perform assigned tasks safely for residents in care
Staff do not ensure medications are dispensed in a timely manner

INVESTIGATION FINDINGS:

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On 11/30/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Lead Staff, Leonida Arinzana. LPA toured the facility, interviewed staff and residents, reviewed staff and resident records and made observations during the course of the investigation.
Complaint alleges, staff do not ensure resident records are properly maintained. Based on a review of resident records, LPA found all resident records to be in order and current. However, upon a review of staff records, LPA found that staff (S1) & (S2) do not have current Health Screening Reports on file. Based on an interview with Administrator, it was indicated that staff (S1 & S2) have attempted several times to update their documents but have been unsuccessful.
Complaint alleges, Licensee does not ensure staff are in good physical, mental health to perform assigned tasks safely for residents in care. Upon a review of staff records, LPA found that staff (S1) & (S2) do not have current Health Screening Reports on file determining if they are in good physical and mental condition to perform duties.
Continued onto LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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 6

Control Number 21-AS-20230828110508

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: 11/30/2023

NARRATIVE

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Staff do not ensure medications are dispensed in a timely manner. Based on a review of medication records LPA found that staff did not properly administer resident (R3) prescription medication. In addition, based on interview with staff (S1) it was found that S1 was not following R3's prescription of several medications to be administered in the morning daily and instead stated that S1 was administering in the evening. S1 also stated that the Medication Administration Record (MAR) was not completed for the entire month of October. Upon review of files LPA confirmed the missing MAR document.

Allegations, staff do not ensure resident records are properly maintained and Licensee does not ensure staff are in good physical, mental health to perform assigned tasks safely for residents in care and staff do not ensure medications are dispensed in a timely manner are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegations are valid because the preponderance of the evidence standard has been met.

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
08/28/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20230828110508

FACILITY NAME:	GOOD SAMARITAN CARE HOME		FACILITY NUMBER:	486804114
ADMINISTRATOR:	DE GUZMAN, JANOLYN R.		FACILITY TYPE:	740
ADDRESS:	506 LABRADOR WAY		TELEPHONE:	(650) 532-4317
CITY:	SUISUN CITY	STATE: CA	ZIP CODE:	94585
CAPACITY:	6	CENSUS: 3	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	01:47 PM
MET WITH:	Leonida Arinzana, Lead Staff		TIME COMPLETED:	06:10 PM

ALLEGATION(S):

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Facility does not ensure residents are accorded dignity in their personal realtionships with staff while in care
Staff do not ensure residents receive adequate food service in a timely manner

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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 6

Control Number 21-AS-20230828110508

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: 11/30/2023

NARRATIVE

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Complaint alleges staff do not ensure residents receive adequate food service in a timely manner. Based on multiple visits and tours of the facility, LPA observed an sufficient amount of food available for residents in care. In addition, LPA observed residents on multiple occasions being provided meals during tours of the facility. LPA unable to find corroborating evidence supporting the allegation.

Allegations, facility does not ensure residents are accorded dignity in their personal relationships with staff while in care, & staff do not ensure residents receive adequate food service in a timely manner are 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. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 21-AS-20230828110508

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: 11/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/01/2023 Section Cited CCR 87465(a)(4	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical & Dental Care - The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee has agreed to schedule a in-service training for all staff on medication administration. Training date to be submitted to CCL by 12/1/2023. In addition, to conduct a full medication audit for all resident ensuring medication count and medication records are in order.
	8 9 10 11 12 13 14	Based on multiple spot medication counts LPA found that staff did not properly assist in administering prescribed medication for resident (R3). In addition, upon interview with staff S1 it was found that S1 admitted to not completing the Medication Administration Record for October 2023. This is an immediate health & safety risk to residents in care.	8 9 10 11 12 13 14	LIC9098 Proof of Corrections Form confirming completion of medication audit is to be submitted to CCL by POC date 12/7/2023.
Type B 12/07/2023 Section Cited CCR 87412(a)(11)	1 2 3 4 5 6 7	87412(a)(11)Personnel Records - A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Licensee has agreed and schedueld staff S1 and S2 to obtain a health screening, including a TB test, and results, on 2/1/23. Licensee to submit copies of the documents by POC due 12/7/23.
	8 9 10 11 12 13 14	Based on review of records, Staff S1 & S2 lack a health screening report, required for personnel records. The licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 21-AS-20230828110508

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: 11/30/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/07/2023 Section Cited CCR 87411(f)	1 2 3 4 5 6 7	87411(f)Personnel Requirements – General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has agreed and schedueld staff S1 and S2 to obtain a health screening, including a TB test, and results, on 12/1/23. Licensee to submit copies of the documents by POC due 12/7/23.
	8 9 10 11 12 13 14	Based on review of records, Staff S1 & S2 lack a health screening report, including TB test and results. the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons 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.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

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