507003970-12-19-2023-27-AS-LKIG-CYRN33-20231222090539

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507003970
Report Date: 12/15/2023
Date Signed: 12/19/2023 05:32:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2023 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230728152451

FACILITY NAME:	DAVIS GUEST HOME VI		FACILITY NUMBER:	507003970
ADMINISTRATOR:	HEATHER MCCLOSKY		FACILITY TYPE:	740
ADDRESS:	1209 CENTRAL AVENUE		TELEPHONE:	(209) 538-1496
CITY:	MODESTO	STATE: CA	ZIP CODE:	95351
CAPACITY:	9	CENSUS: 9	DATE:	12/15/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ariel Thomas and Misty Speegle		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Resident sustained an unexplained fracture while in care

Staff are not addressing change in resident’s condition

Staff changed resident’s medication without authorization

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 12/15/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregiver, Ariel Thomas, who was briefly interviewed. This LPA requested that the facility caregiver go ahead and contact the facility designated Administrator, Heather McClosky, to inform her that CCL was present at this time.
The other facility designated Administrator, Misty Speegle, arrived shortly thereafter to this facility.
Current census was 9 residents.
The purpose of this visit was to deliver the findings of this investigation to this facility and its designated representatives at this time.
Based on a review of the forms and documents that was retrieved during the course of this investigation, it was learned that R1 sustained an unwitnessed fall on 06/03/2023 and complained of discomfort and head related pain possibly from hitting R1's head on any surrounding furniture in R1's room. The facility personnel contacted 911 and had R1 transported to the local medical establishment for further review and evaluation. R1 was discharged later that same day to this facility without mention of any rib fractures.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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-20230728152451

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DAVIS GUEST HOME VI	FACILITY NUMBER: 507003970
	VISIT DATE: 12/15/2023

NARRATIVE

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On 06/04/2023 R1 was still complaining of pain and discomfort and specified that R1 was suffering from chest and rib pains. Facility personnel contacted 911 and had R1 transported back to the local medical establishment where she was then diagnosed with a rib fracture and discharged with corresponding medications.
Based on interviews and information gathered, it was learned that facility personnel were unaware of the rib fracture from the initial fall sustained on 06/03/2023 since it was not diagnosed by the local medical establishment and only addressed the issue of the possible head injury. It was learned that once it was properly diagnosed and documented that R1 had sustained a rib fracture by the local medical establishment on 06/04/2023, facility personnel then addressed the change in care and supervision at that time.
It was learned that Nurse Practitioner, Karlene Bert, was employed under the medical group for licensed medical professional Rex Adamson. It was observed that there were several changes and amendments made to the prescribed medications for R1 during R1's admission to this facility. It was observed that all changes and amendments that were conducted for R1 had corresponding documents from the Nurse Practitioner, Karlene Bert, in lieu of the licensed medical professional Rex Adamson. All changes were properly documented and observed at this time. Nurse Practitioner Karlene Bert and licensed medical professional Rex Adamson were not employees of this 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 violations occurred.

There were no deficiencies observed or cited at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC9099 (FAS) - (06/04)

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