486804114-9-6-2024-21-AS-VBEI-D96UGH-20240916153422

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804114
Report Date: 09/06/2024
Date Signed: 09/06/2024 10:54:46 AM

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
05/22/2024 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20240522133358

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: 2	DATE:	09/06/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Katherine Santos, Caregiver and LicenseeLuningning Sikat via phone		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Physical Abuse

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPA) Nakagawa arrived unannounced to deliver findings regarding the above complaint and met with Katherine Santos, Caregiver and Luningning Sikat, Licensee via phone.

The c omplaint alleges that staff, S1 grabbed a resident by their arms during an argument resulting in the resident being bruised. During investigation, LPAs conducted interviews and made observations. Interview with another staff, S2 revealed that staff S1 also had a physical altercation with S2 the same day as their argument with R1. When Licensee came to facility the following day to address the staff altercation, R1 reported to the Licensee that S1 had grabbed their arms. S1 was terminated and escorted outside. The police were called and responded to the facility where they conducted interviews and arrested S1 for elder abuse.

Continued on 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

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

Control Number 21-AS-20240522133358

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: 09/06/2024

NARRATIVE

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Continued from 9099...

LPAs observed that R1 presented with bruising on their arms and during interview was able to tell LPAs what happened, which was consistent with the story they told police and the Licensee.

The allegation that staff physically abused a resident is Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. 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: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20240522133358

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: 09/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/06/2024 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.	1 2 3 4 5 6 7	Licensee to remove staff member S1 from facility and duties.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews conducted by LPAs, and police report, which is an immediate health, safety and personal rights risk to the residents in care	8 9 10 11 12 13 14
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	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: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024

LIC9099 (FAS) - (06/04)

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