507001184-12-24-2021-27-AS-SRIN-CABN8Z-20220103091511

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507001184
Report Date: 12/23/2021
Date Signed: 12/24/2021 01:28:57 PM

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
09/20/2021 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210920095837

FACILITY NAME:	DAVIS GUEST HOME #5		FACILITY NUMBER:	507001184
ADMINISTRATOR:	HEATHER MCCLOSKY		FACILITY TYPE:	740
ADDRESS:	2405 MAUNA LOA DRIVE		TELEPHONE:	(209) 556-9204
CITY:	CERES	STATE: CA	ZIP CODE:	95307
CAPACITY:	8	CENSUS: 7	DATE:	12/23/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Heather McClosky		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mishandled resident's funds

Staff did not safeguard resident's belongings

Staff did not assist resident with obtaining care

Staff did not provide water to resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unannounced complaint visit made out to this facility on 12/23/2021 by LPA Charlie Yang. This LPA was met by the facility house manager, Maria Bravo, and facility caregiver, Brittany Miller, who was requested by this LPA to go ahead and contact the facility designated Administrator, Heather McClosky, who arrived shortly thereafter to this facility.
Current census was 7 residents.
Based on a review of the resident records, it was learned that all residents and their P&I funds were managed by this facility and its staff. Withdrawals and deposits were recorded and initialed by the corresponding resident after each transaction. Additional information revealed that R1 would also order items through Amazon, an online retail store, with the assistance of facility staff. Records revealed that items were ordered, paid for, and delivered to this facility address as ordered.
Based on interviews, it was learned that adequate care and supervision was being provided to the residents by facility staff. It was learned that incontinent residents were properly cleaned and changed by staff from all shifts throughout the day and night as well.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

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-20210920095837

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 #5	FACILITY NUMBER: 507001184
	VISIT DATE: 12/23/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews, it was learned that meals were served three times a day with two snacks in between meals. Along with the meals a variety of drinks were made available to facility residents upon request if water or juice was not wanted at that time. It was learned that milk and coffee were also made available if desired by facility residents at meal time.

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.

Exit Interview

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2