507004748-11-23-2021-27-AS-KHOS-C9ANCG-20211201092042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004748
Report Date: 11/22/2021
Date Signed: 11/23/2021 09:55:49 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
03/30/2021 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210330161852

FACILITY NAME:	EMPIRE GUEST HOME		FACILITY NUMBER:	507004748
ADMINISTRATOR:	JOAN LITTLE		FACILITY TYPE:	735
ADDRESS:	101 SOUTH G STREET		TELEPHONE:	(209) 522-1441
CITY:	EMPIRE	STATE: CA	ZIP CODE:	95319
CAPACITY:	23	CENSUS: 21	DATE:	11/22/2021
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Mark and Joan Little		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not seek resident timely medical attention.

INVESTIGATION FINDINGS:

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Unannounced complaint visit made out to this facility on 11/22/2021 by LPA Charlie Yang and was met by the facility designated Administrator Joan Little and Mark Little. Brief interview conducted with facility personnel.
Current census was 21 residents of which 11 were not present since they were attending their respectable day programs at this time.
The purpose of this visit was to complete the complaint investigation and convey the findings to the facility representatives at this time.
Based on interviews it was learned that resident, R1, had a ring on his right middle finger which R1 had worn for several years. A review of R1's hand was conducted and it appeared to naturally be darker in color with larger fingers. Interview revealed that R1 did not have any significant pain until recently and R1 did approach the facility designated Administrator, Joan Little, to inform her of this issue. R1 participated in daily activities and did not show any hindrances with pain or discomfort in R1's right hand.
Based on interviews and documents reviewed, the facility designated Administrator did take R1 to the emergency room upon discovery of R1's discomfort with his right middle finger.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

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-20210330161852

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: EMPIRE GUEST HOME	FACILITY NUMBER: 507004748
	VISIT DATE: 11/22/2021

NARRATIVE

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It was learned that a wound had developed under the ring after it was cut off by facility personnel. Medical attention was sought and home health did follow up with R1 for wound care.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation 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 during today's complaint visit.

Exit Interview

SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021

LIC9099 (FAS) - (06/04)

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