507002396-4-6-2021-27-AS-SRIN-BZUVMK-20210407163341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507002396
Report Date: 04/06/2021
Date Signed: 04/06/2021 03:34:03 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
10/01/2020 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201001164200

FACILITY NAME:	SAMARITAN VILLAGE		FACILITY NUMBER:	507002396
ADMINISTRATOR:	RIKKI PEREZCHICA		FACILITY TYPE:	740
ADDRESS:	7700 FOX ROAD		TELEPHONE:	(209) 883-3000
CITY:	HUGHSON	STATE: CA	ZIP CODE:	95326
CAPACITY:	277	CENSUS: 157	DATE:	04/06/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Telephone - Administrator Rikki Perezchica Due to Precautions for COVID-19		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident is being over charged on fees
Staff did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace contacted the facility via telephone to conclude a complaint investigation due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the allegations with the Administrator.

Allegations:
Staff did not safeguard resident's personal belongings
Resident is being over charged on fees

Based on LPA interviews with staff, administrator, and power of attorneys (POA's) for residents; the facility provided letters to residents and POA's for changes in rates, care, or anything else pertaining to residents in care of the facility. The allegation resident is being over charged on fees; therefore the allegation is deemed UNFOUNDED. This agency has investigated the allegation noted above and have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. We have therefore, dismissed the complaint.
Continued on 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

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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Control Number 27-AS-20201001164200

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: SAMARITAN VILLAGE	FACILITY NUMBER: 507002396
	VISIT DATE: 04/06/2021

NARRATIVE

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Continued from 9099 - Page 2

Based on interview with staff, administrator and POA's there is no evidence of staff not safeguarding resident's personal belongings. The refrigerator had rotten and moldy food due to resident storing it for long periods of time and Wanda's daughters are the ones who asked staff to clean out refrigerator. The allegation of staff did not safeguard resident's personal belongings; therefore the allegation is deemed UNFOUNDED. This agency has investigated the allegation noted above and have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. We have therefore, dismissed the complaint.

An exit interview was conducted with Administrator via telephone and a copy of this report LIC 9099, LIC 9099-C, LIC 858- Client Records, LIC 811- Confidential Names, and Appeal Rights was provided to the Administrator via email and an electronic email read receipt confirms receiving these documents. Administrator will send 9099 and 9099-C back via email signed to LPA Wallace.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
10/01/2020 and conducted by Evaluator Ruth Wallace

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20201001164200

FACILITY NAME:	SAMARITAN VILLAGE		FACILITY NUMBER:	507002396
ADMINISTRATOR:	RIKKI PEREZCHICA		FACILITY TYPE:	740
ADDRESS:	7700 FOX ROAD		TELEPHONE:	(209) 883-3000
CITY:	HUGHSON	STATE: CA	ZIP CODE:	95326
CAPACITY:	277	CENSUS: 157	DATE:	04/06/2021
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Telephone - Administrator Rikki Perezchica Due to Precautions for COVID-19		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident not treated with dignity

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ruth Wallace contacted the facility via telephone to conclude a complaint investigation due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the allegation with the Administrator.
Allegation:
Resident not treated with dignity
LPA interviewed staff, administrator, and Power of Attorney’s (POA's) of the two residents. LPA did not find any evidence of facility threatening to give resident (R1) a thirty day eviction notice or administrator treating R1 "like a two-year-old. LPA did not find any evidence of resident (R2) not being treated with dignity regarding unprofessional language. R2 has been inappropriate at times due to the nature of her mental and physical state. Therefore; the allegation that resident not treated with dignity is deemed UNSUBSTANTIATED. There was not a preponderance of evidence to prove or disprove that the allegation occurred as reported therefore the allegation was found to be Unsubstantiated.
An exit interview was conducted with Administrator via telephone and a copy of this report 9099-A and Appeal Rights was provided to the Administrator via email and an electronic email read receipt confirms receiving these documents. Administrator will send 9099-A back via email signed to LPA Wallace.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth Wallace	TELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2021

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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