507002708-12-5-2022-27-AS-KHOS-CLWT79-20221208132822

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507002708
Report Date: 11/30/2022
Date Signed: 12/05/2022 11:04:00 AM

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
09/07/2022 and conducted by Evaluator Arielle Pascua

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220907111051

FACILITY NAME:	ST. CHARLES MANOR		FACILITY NUMBER:	507002708
ADMINISTRATOR:	WOODRUFF, DORIS		FACILITY TYPE:	735
ADDRESS:	3316 ST. ANN WAY		TELEPHONE:	(209) 483-8725
CITY:	MODESTO	STATE: CA	ZIP CODE:	95355
CAPACITY:	6	CENSUS:	DATE:	11/30/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Oscar Dayrit		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility not providing a healthy environment by allowing residents smoke cigarettes in room
Staff are not practicing safe food storage and preparations.
Staff are unable to communicate with residents due to language barrier.
Staff are not keeping an adequate medication record for residents.
Facility administrator is not present at facility.

INVESTIGATION FINDINGS:

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On 11/30/2022 at 10:00am, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA Pascua met with Facility Designated Representative, Emma Obrero and explaiend the purpose of this visit. The purpose of this visit was to deliver complaint findings for the allegations above.
A brief interview with FDR Obrero was conducted.. Current Census was 4.
During the course of this investigation LPA Pascua conducted several staff and resident interviews and reviewed facility documents.
Allegation: Facility not providing a health environment by allow residents smoked cigarettes in room.
Based on 4 staff interviews, 4 out of 4 staff members stated that smoking inside the facility has never been allowed inside the facility. 4 out of 4 staff members state that there is one resident who is a chronic smoker but has never seen them smoke inside their room but instead will smoke outside in the facilities designated smoking area. LPA Pascua also conducted 3 resident interviews. 1 out 3 residents state that they smoke outside in the designated smoking area. 2 out 3 residents state that they have not seen anyone smoke inside their room. 3 out of 3 residents are aware of the designated smoking area and where it is.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

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-20220907111051

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: ST. CHARLES MANOR	FACILITY NUMBER: 507002708
	VISIT DATE: 11/30/2022

NARRATIVE

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LPA Pascua did not observe ash trays, or indication that he was smoking cigarettes inside his room. LPA Pascua did observe an area on the back patio with an ash tray that facility staff says is the designated smoking area. Based on interviews and LPA observation it is unclear if the facility allows residents to smoke in their room.

Allegation: Staff are not practicing safe food storage and preparations.
LPA Pascua observed that perishable food located in the refrigerator are dated and labeled based on when the facility bought the items. LPA Pascua interviewed 4 staff members, 4 out of 4 staff members stated that they label the food based on when the facility bought the items and will follow the first in and first out method when preparing food for the residents. 4 out of 4 staff members state that they defrost any frozen protein in the refrigerator with plastic wrap over it away from any other food. 4 out 4 staff members state that as soon as the residents are done eating, left over food will be placed in the refrigerator or thrown away. LPA Pascua also interviewed 3 residents. 3 out of 3 residents state that they have not seen any issues with their food and enjoy the food that is cooked for them. 3 out of residents state that their food has never been moldy or in state where it cannot be eaten. Based on interviews and LPA observation it is unclear if the facility is not practicing safe food storage and preparation at this time.

Allegation: Staff are unable to communicate with residents due to language barrier.
Based on staff interviews, 4 out of 4 staff members state that they believe that they are able to communicate with the residents efficiently. 1 out of 4 staff members state that one resident is known to mumble and may as for them to speak up or speak slowly in order for them to understand the resident. LPA Pascua also interviewed 3 residents. 3 out 3 residents state that they do not have any issues communicating with staff about their needs. During LPA Pascua's visit, LPA Pascua did not observe communication issues between residents and staff. Based on interviews and LPA observation it is unclear that the staff is unable to communicate with the residents based on a language barrier.

Allegation: Staff are not keeping an adequate medication record for residents.
Based on an interview with Facility Designated Administrator, Dorris Woodruff, it was learned that R1 was diagnosed with Diabetes but was able to handle his medication on his own. FDA Woodruff stated that R1 denied any help from the facility to remind them of taking the medication. FDA Woodruff stated that the facility prepared a Medication Administration Record for the resident in case that they needed it. FDA Woodruff also stated that she spent time with R1 to explain the importance of ensuring that they take their medication daily.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220907111051

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: ST. CHARLES MANOR	FACILITY NUMBER: 507002708
	VISIT DATE: 11/30/2022

NARRATIVE

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FDA Woodruff stated that the resident did not allow the facility to hold on to his medication and was told that the resident would be keeping it in a locked area in their room. LPA Pascua also interviewed R1's Service Coordinator (SC) and it was stated that the regional center was not aware of the R1's diabetes until after the admission to the facility. R1's SC reported that R1 did not inform the regional center prior to moving into the facility. LPA Pascua also reviewed R1's Restricted Health Condition Health Plan (RHCHP) and it states that R1 is independent and is able to provide the services for himself and will ask the facility for help as needed. It is unclear at this time that the facility did not provide an adequate medication record for R1.

Allegation: Facility administrator is not present at facility.
Based on interviews, 3 out of 3 staff members state that the Facility Administrator is present at the facility twice a week and will be at the facility from 9:00am-4:00pm. 3 out of 3 staff members state that the Facility Administrator is always available to them when needed. 3 out of 3 staff members also state that when the Facility Administrator is present, she is doing administrative work. LPA Pascua also reviewed the LIC500 and Staff Schedule and it states that the Facility Administrator is present on varying days but will be at the facility twice a week from 9:00am-4:00pm. LPA Pascua also reviewed facility files and it was observed that both staff and resident files in compliance at this time. It is unclear at this time at the Facility Administrator is not present at the facility.

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.

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC9099 (FAS) - (06/04)

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