486804149-9-24-2024-21-AS-BMOS-D9FU6D-20240925151810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804149
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:04:40 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, 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
08/06/2024 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240806155457

FACILITY NAME:	SAKURA HOME 2		FACILITY NUMBER:	486804149
ADMINISTRATOR:	BALUYOT, JENNA NICHOLE		FACILITY TYPE:	735
ADDRESS:	2024 SWAN WAY		TELEPHONE:	(916) 743-9292
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94533
CAPACITY:	4	CENSUS: 2	DATE:	09/24/2024
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Jenna Baluyot (Administrator)		TIME COMPLETED:	03:19 PM

ALLEGATION(S):

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-Staff did not ensure resident was provided their medication as prescribed.
-Staff are not adequately trained.
-Staff physically abuse client in care.
-Personal Rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Jenna Baluyot, Administrator.

The Department received an allegation of staff did not ensure resident was provided their medication as prescribed. Per Reporting party, on 8/6/24 client (C1) at around 8am was taken to Kaiser Vacaville Emergency Room due to behavioral outburst. Reporting party expressed that around 1:30pm staff told the crisis team that they forgot to bring C1’s medication because it was left at the home, which it was presumed that it was a PRN or a scheduled medication, but C1 referred to it as their “calming medication”. Based on interviews conducted with staff (S1) it was confirmed that they did not offer or bring C1’s Olanzapine 5mg tabs, because C1 was experiencing an escalation of agitation, aggressive behavior towards client (C2) and staff had to intervene to stop C1 from granting access to C2’s bedroom and medication was prescribed to either provide 1 tab or half of tablet twice per day. Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

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 4

Control Number 21-AS-20240806155457

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: SAKURA HOME 2	FACILITY NUMBER: 486804149
	VISIT DATE: 09/24/2024

NARRATIVE

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Continue from LIC9099...

Based on records review of C1’s physician report dated 7/5/24, centrally stored medication and destruction record, facility medication administration records (MAR) for the month of August 2024 confirmed that medication Olanzapine 5mg tabs were prescribed as follow: “take 1 tablet by mouth nightly for psychosis. Can take up to half tablet (2.5mg) twice daily as needed for agitation”. The MAR records indicated that C1 was assisted by staff with the medication as prescribed by their physician nights prior to the incident. A finding that the complaint allegation of staff did not ensure resident was provided their medication as prescribed is unsubstantiated meaning that although the allegations 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.

Another allegation was received about staff are not adequately trained. The Reporting party raised concerns about staff training due to accompanying staff (name unknown) stated that client (C1) had been escalating for a couple of days into agitation and aggressive behavior, where the police had to be called out three times to the facility, but when staff was inquired regarding the type of intervention that they provide at the facility, staff did not have an answer. Based on records review, LPA reviewed staff training records (S1, S2, S3, S4 & S5) have received hours annual of training required per regulation. Based on LPA’s interviews conducted with staff (S1, S2 & S3) confirmed that they have received training and have described the techniques of de-escalation provided to them during their training including, but not limited to active listening, redirection, relaxation, structure choices, active ignoring, verbal contact, differential reinforcement, screening techniques, voice tone and speed, use of touch to get attention by using gestures and body language for clarification, allowing time for client to respond. The techniques described appears to be adequate for this type of incidents. A finding that the complaint allegation of staff is not adequately trained is unsubstantiated meaning that although the allegations 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.

Continues on LIC9099C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20240806155457

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: SAKURA HOME 2	FACILITY NUMBER: 486804149
	VISIT DATE: 09/24/2024

NARRATIVE

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Continues from LIC9099C...

The Department received various reports from different agencies regarding concerns of staff physically abuse client in care. Per reporting parties, C1 did not want to return to the home because the way they were being treated by S2 and another client C2 at the home. C1 stated to reporting party that S2 is grabbing their throat and puts them up against the wall. Although, staff (unknown name) that were present stated that C1 has a history of making up stories. Another reporting party reported that C1 stated they were choked by S2, date of the choking incident is unknown, but the reporting party believes it was recent, but there were no marks or injuries noted on C1’s neck, but C1 stated that their neck was hurting. Based on records review of C1’s individual program plan revealed that there were previous incidents of C1 displaying emotional outburst with physical/verbal aggression and property destruction as well as fabricating stories causing a health and safety risk to them and other individuals in the home. Based on LPA’s interviews conducted with S2, staff indicated that C1 is not part of their assigned clients, they do not usually interact with C1, except on 8/6/24 during C1’s behavioral outburst, S1 has been hit by C1, so S2 came to help S1 by placing themselves between S1 and C1 to block C1 from keep hitting their coworker. Per S2, they told C1 to relax and calm down, but C1 was very agitated, aggressive and didn’t listen their instructions. According to S1, the incident information above described was corroborated. Also, statements obtained by LPA from outside parties who did confirm C1’s behavioral challenges and they ensured LPA that there were no concerns regarding the care and safety that C1 was receiving while residing at the facility. LPA learned based on records review and interviews with staff and outside parties that there was no information provided to support that violation occurred regarding facility staff physically abuse client in care. A finding that the complaint allegation of staff physically abuse client in care is unsubstantiated meaning that although the allegations 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.

Continues on LIC9099C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 21-AS-20240806155457

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: SAKURA HOME 2	FACILITY NUMBER: 486804149
	VISIT DATE: 09/24/2024

NARRATIVE

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Continued from LIC9099C...

Last allegation received about personal rights. Per Reporting party, C1 claims that C2 makes racial slurs, bangs on windows, and plays piano loudly disturbing C1’s rest on purpose. During LPA’s visit to the facility on 8/7/24, LPA toured the facility, it was observed that C1’s bedroom is located across C2’s bedroom. Based on LPA’s interviews with staff, it was confirmed that C2 plays the piano during normal business hours at a normal level, but C1 gets "jealous" because C2 maintains close relationship with their responsible parties. Although, C1 can communicate with their responsible parties, the interaction with one of them triggers their emotional outburst due to other issues. Statements obtained by LPA from C1’s responsible parties confirmed the above information, and they did not consider that any violation of personal rights have occurred to C1 while residing at this facility. C1 was relocated as of 8/14/24 to another facility due to C1 needed a higher level of care to meet their behavioral needs. However, during the investigation there was no information or supporting evidence that could indicate that any of the incidents above mentioned have happened at a prior date. A finding that the complaint allegation of personal rights is unsubstantiated meaning that although the allegations 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.

No deficiencies cited during this visit.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024

LIC9099 (FAS) - (06/04)

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