490108000-7-20-2020-21-AS-HDBI-BRPVZV-20200720165319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 490108000
Report Date: 07/10/2020
Date Signed: 07/20/2020 01:50:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/22/2020 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20200422110651

FACILITY NAME:	MC HUGH CARE HOME		FACILITY NUMBER:	490108000
ADMINISTRATOR:	DIZON, TIFFANY		FACILITY TYPE:	740
ADDRESS:	1000 GORDON LANE		TELEPHONE:	(707) 545-8213
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	15	CENSUS: 13	DATE:	07/10/2020
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Administrator, Tiffany Dizon		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff are not providing resident's medication regularly
Staff do not treat resident with dignity and respect
Staff do not provide adequate food service

INVESTIGATION FINDINGS:

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Licensing Program Analyst Willis met with Administrator, Tiffany Dizon via Televisit in order to deliver findings regarding the above mentioned complaint allegations.

Complaint alleges that resident, R1 feels harassed and bullied by the facility staff and that R1 is not getting enough food. Allegation indicates that staff do not provide food between scheduled mealtimes and the staff take meals away from residents if they take too long to eat. Complaint further alleges that staff threw R1's personal belongings over the facility fence into the backyard. Complaint also alleges that R1's medication is not given to them regularly though complaint is unable to provide information about what medication was skipped and how many times it was missed.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2020

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-20200422110651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MC HUGH CARE HOME	FACILITY NUMBER: 490108000
	VISIT DATE: 07/10/2020

NARRATIVE

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Continued from LIC9099

During investigation, LPA conducted interviews of staff and residents, made observations and reviewed documents. According to staff interview resident, R1 refused medication and then wanted their medication later but the window of time that the medication is allowed to be taken was past. Facility's Medication Administration Record shows that R1 refused medication twice in April, 2020.

Complaint indicates that R1 was going through their bag to determine which items they would be keeping when a staff snatched their bag and threw it over the fence. Interviews of staff and residents indicated that R1 had their personal belongings throughout the facility and refused to pick up the items. LPA was provided pictures of items in the dining room, living room and the front porch. According to staff, after R1 refused to move their items, staff put their items on the back enclosed porch. During Televisit dated 4/27/2020, LPA observed that items were in a pile on the enclosed porch. Staff and resident interviews denied seeing anyone throw items over the fence.

Complaint alleges that staff do not provide food in between meals and staff take resident's food if they take too long to eat. Document provided to LPA shows that meals are provided as follows: Breakfast - 7:30am, Morning Snack - 9:15am, Lunch - 11:30, Afternoon Snack - 2:00, Dinner - 4:30, Evening Snack - 8:00pm. Interviews indicate that staff will provide fruit or cookies at any time if a resident asks for it. Residents who were interviewed denied ever seeing staff take somebody's food if they take too long to eat.

Based on evidence obtained during the investigation, a finding that the complaint allegations that staff are not providing resident's medication regularly, staff do not treat resident with dignity and respect and staff do not provide adequate food service was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred. We have therefore dismissed the complaint.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2020

LIC9099 (FAS) - (06/04)

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