507004748-9-25-2023-27-AS-KHOS-CWHL6W-20231011082925

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 507004748
Report Date: 09/25/2023
Date Signed: 09/25/2023 03:11:53 PM

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
08/24/2023 and conducted by Evaluator Jamie Ivey-Canady

COMPLAINT CONTROL NUMBER: 27-AS-20230824102036

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: 23	DATE:	09/25/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Joan Little		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff did not store resident's medications locked and inaccessible to residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA)s Jamie Ivey Canady and Albert Johnson arrived to the facility unannounced to conduct a complaint investigation visit. Before stepping into the facilthy, LPA Ivey Canady questioned if there was Covid 19, Bed Bugs, Roaches, or Scabies at the facility. Caregiver stated no. LPAs met with administrator Joan Little, and explained the purpose of the visit. LPAs toured the facility and LPAs observed the medication to be locked and unaccessible to residents. While conducting an interview with the administrator, facility staff approached the table and informed LPAs there is one resident in the facility with Scabies. Facility Staff looked at administrator and said "it was asked if there was scabies here" For safety precautions LPAs moved the visit outdoors.

There are currently 3 residents in the facilty and 20 residents have gone to day program. There 2 caregiver's in the facility to include the administrator Joan.LPAs requested additonal medication log documents and facility chart notes. LPAs conducted interviews with 2 current facility staff and 1 resident.
Con't 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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-20230824102036

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: 09/25/2023

NARRATIVE

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On 9/5/2023 LPA Ivey Canady received and reviewed facility documents. On 9/25/2023 LPA Ivey Canady received and reviewed additional facility documents including facility training documents, medication files and medication logs. According to facility training documents, facility staff are trained regarding Title 22 regulations for storing medication in the facility.

On 9/25/2023 LPAs conducted interviews with facility staff and one resident. According to resident interviews, facility medication logs and chart notes, the medication cabinet is locked at all times when it is not being accessed by staff to pass out medication. According to LPA observation, facility medication storage locker was locked upon arrival. Based on facility staff and resident interviews, facility file reviews and medication logs, the facility medication locker stays locked based on Title 22 regulations. Therefore, the allegation Staff did not store resident's medications locked and inaccessible to residents is unsubstantiated.
An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Per California Code of Regulations (CCR), Title 22, no deficiencies were observed during the visit. An exit interview was held with Administrator Joan Little, and copy of the report provided via email due to scabies exposure..

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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