500300107-4-19-2022-27-AS-SDOB-CEL7DS-20220519213448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 500300107
Report Date: 04/19/2022
Date Signed: 04/19/2022 12:58:17 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/10/2022 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20220310144004

FACILITY NAME:	CASA DE MODESTO		FACILITY NUMBER:	500300107
ADMINISTRATOR:	JENNIFER BICEK		FACILITY TYPE:	740
ADDRESS:	1745 ELDENA WAY		TELEPHONE:	(209) 529-4950
CITY:	MODESTO	STATE: CA	ZIP CODE:	95350
CAPACITY:	84	CENSUS:	DATE:	04/19/2022
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:			TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident sustained a bruise while in care

Staff did not seek medical care for resident

Staff did not inform responsible party of resident's change in condition

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility by Licensing Program Analyst (LPA) Jason Lund who was met by the Administrator, Okey Onyeagucha. LPA Lund explained to Administrator Okey Onyeaguch the reason for the visit.

Resident sustained a bruise while in care- Based on interviews and records review. On 1/9/2022 Resident (R1) son called Global Hospice and stated that R1 may have fell and had noted bruising to the right eye. Hospice assessed R1 who verbally denied pain. Caregivers interviewed reported R1 did not fall but bruising may have been caused by R1 hitting head on bed rails. Staff reported to Hospice that R1 is restless and stays awake at night. Due to medical conditions, R1 is a poor historian and was unable to report how bruise was sustained. It was unclear if bruising was caused by R1 or due to some other reason, therefore the allegation was deemed unsubstantiated.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

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 27-AS-20220310144004

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CASA DE MODESTO	FACILITY NUMBER: 500300107
	VISIT DATE: 04/19/2022

NARRATIVE

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Staff did not seek medical care for resident- Based on interviews and records review Resident (R1) had hospice through Global Hospice. On 1/9/2022 at 1055 hours hospice communications log states that R1’s son called reporting R1 may have fallen again. Hospice notes also show additional incidents where facility called to report falls and changes in condition to R1. It is unclear if there were incidents that were not reported as R1 was unable to confirm or deny not receiving medical care, therefore the allegation was unsubstantiated.

Staff did not inform responsible party of resident's change in condition- It was alleged that R1 had a change in condition due to multiple falls that was not reported to responsible party of R1. Based on records reviewed, incident reports for the falls note that responsible party for R1 was notified. R1 started receiving hospice services on 9/14/2021. In early December 2021, hospice noted that R1 was showing a slow and steady decline which included a decrease in appetite and increased anxiety in evening hours. Towards the end of December 2021 to early January 2022, Hospice notes states Resident (R1) began to show excessive sleep, restlessness, crying, and agitation with staff at times. Hospice notes also show that the responsible party was notified of the decline of R1. It is unclear if all incidents were reported to responsible party of R1 as R1 was unable to report if there were additional falls not reported, therefore the allegation was deemed unsubstantiated

The Department (CCLD) has found the allegations. Unsubstantiated.

A finding that the complaint allegation(s) are UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2022

LIC9099 (FAS) - (06/04)

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