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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 507002067
Report Date: 06/01/2021
Date Signed: 06/08/2021 01:42:55 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
07/27/2020 and conducted by Evaluator Tirzah Hubbard
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200727094952
FACILITY NAME:SIERRA SALEM CHRISTIAN HOMES,INC.FACILITY NUMBER:
507002067
ADMINISTRATOR:JERALD PASMAFACILITY TYPE:
735
ADDRESS:309 GAYLE AVENUETELEPHONE:
(209) 572-5050
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY:6CENSUS: 3DATE:
06/01/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Bethany DuttTIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff falsified facility records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 6/01/2021 at 10:50am Licensing Program Analyst (LPA) Tirzah Hubbard and Ashley Boothe conducted an onsite inspection to deliver the investigation findings of the following allegations: "Staff falsafied facility records, "Based on Interviews and records review Staff 1 documented medication incorrectly on MARS. LPA's met with Adminsitrator Bethany and stated the purpose of the visit. Administrator contacted the licensee Jerald Plasma who was present over the phone for this delivery of findings.
During the Investigation LPA TIrzah Hubbard reviewed Resident One's (R1)’s Medication Adminstration Records (MAR). MARS verified R1 recieved the correct medication. Staff 1 documented the medication in MARS incorrectly and notified Administrator of the mistake. The incorrect documentatin on MARS was deleted. Changes were made to R1 MAR to show medication adminsitered as physicians order. The facility uses an electronic MARS system and oncall staff have access to permanent staff logins. Although the allegation 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 allegations are UNSUBSTANTIATED.No deficiencies were cited on todays visit. An exit interview was held and a signature on this report acknowledges a copy was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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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