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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 502700233
Report Date: 09/15/2023
Date Signed: 09/21/2023 03:14:01 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
06/08/2023 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230608093304
FACILITY NAME:DAVIS GUEST HOME #8FACILITY NUMBER:
502700233
ADMINISTRATOR:SPEEGLE, MISTYFACILITY TYPE:
740
ADDRESS:5348 KIERNAN AVENUETELEPHONE:
(209) 622-2042
CITY:SALIDASTATE: CAZIP CODE:
95368
CAPACITY:80CENSUS: 78DATE:
09/15/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Zak Davis TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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9
Facility staff are over medicating resident.
Facility staff does not allow resident to leave the facility.
INVESTIGATION FINDINGS:
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On 09/15/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA Pascua was greeted by Facility Designated Administrator, Zak Davis and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above.
Current census was 78. A brief interview with FDA Davis was conducted.
Allegation: Facility staff are over medicating resident.
It was alleged that facility staff are over medication resident. During the course of this visit, LPA Pascua conducted interviews and reviewed facility records. Based in interviews conducted, it was learned that R1 has been residing at the facility since 2018 and needs consistent prompting when asked to get ready to leave the facility, go to the bathroom, and take medication. It was denied by all staff that have been interviewed that R1 has been overmedicated. LPA reviewed Medication Administrator Records and medications for R1. There are no indications on that show that the resident was provided more medication that has been directed by the physician.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
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 2
Control Number 27-AS-20230608093304
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: DAVIS GUEST HOME #8
FACILITY NUMBER: 502700233
VISIT DATE: 09/15/2023
NARRATIVE
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As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility staff does not allow resident to leave the facility.
It was alleged that facility staff does not allow resident to leave the facility. During the course of this investigation LPA conducted interviews and reviewed facility records. Based on interviews conducted it was learned that the facility cannot allow residents to leave the facility until they have gotten notification from their county conservator that they will be leaving the facility. It was stated by staff that it is usually best practice to have the conservator call prior to the resident leaving to ensure that they are ready on a timely manner and to ensure that they are leaving in a safe manner. It was learned that R1's family members attempted to leave with R1 but the facility did not get notification from their conservator that they are to leave the facility. Based on record review, it was learned that R1 is currently conserved by Napa County. LPA receieved confirmation from the conservator that the the resident's are not allowed to leave the facility unless otherwise stated by them.
As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited at this time. An exit interview was conducted, a copy of the 9099 and 9099-C was provided to the facility.
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle PascuaTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2023
LIC9099 (FAS) - (06/04)
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