515002949-4-24-2023-25-AS-LMUZ-CR8VR8-20230425163929

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 515002949
Report Date: 04/24/2023
Date Signed: 04/24/2023 09:48:19 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
01/23/2023 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 25-AS-20230123085045

FACILITY NAME:	DELTA AT HOLLY OAKS		FACILITY NUMBER:	515002949
ADMINISTRATOR:	MELANIE BYRD		FACILITY TYPE:	735
ADDRESS:	1880 LIVE OAK BLVD		TELEPHONE:	(530) 618-5615
CITY:	YUBA CITY	STATE: CA	ZIP CODE:	95991
CAPACITY:	70	CENSUS: 35	DATE:	04/24/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Administrator- Melanie Byrd		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility staff are not adequately supervising resident, resulting in resident hitting other residents and shoving staff.

INVESTIGATION FINDINGS:

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On 04/24/2023, Licensing Program Analyst (LPA) Talwinder Bains arrived unannounced to deliver findings for complaint investigation for allegation listed above. LPA met with Administrator- Melanie Byrd during today's visit and explained the purpose of the visit. . LPA ensured hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask.

The department conducted records review ,facility observations and interviews to investigate the complaint.

**Report continued on LIC9099-C**

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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 25-AS-20230123085045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: DELTA AT HOLLY OAKS	FACILITY NUMBER: 515002949
	VISIT DATE: 04/24/2023

NARRATIVE

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****continued from LIC9099.................

Allegation-Facility staff are not adequately supervising resident, resulting in resident hitting other residents and shoving staff.

The Department conducted a record review, facility observation and interviews with 4 staff members and 3 residents to investigate this complaint. R1 was admitted to the facility in December 2022. Based on staff and resident interviews, R1 did not present behaviors at the time of admittance. However, R1 started to begin to show aggressive behavior with staff and other residents about a month after R1 was admitted to the facility. R1 tried to hit one of the staff (no date provided) but staff decline to report further since nothing major happened. Additionally, R1 tapped R2 on their shoulder on 01/19/23 after dinner but R2 decline to press any charges with R1 and gave a written statement to facility staff regarding that incident since there were no visible injury. After the incident on 01/19/23, R1 had been transferred to the hospital and held on a 51/50 hold for a Psych Evaluation. Based on the information obtained, it has been concluded that R1s aggressive behavior was due to R1s medical condition and facility was providing care and supervision per R1s admission agreement and needs and service plan. The facility sought medical help when facility staff observed R1’s behavior was a risk to the health and safety of staff and residents in care.

Based on interviews conducted by the Department and records review, the preponderance of evidence standards has not been met. Therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No citations were issued during this visit.
Exit interview was conducted with Administrator and a copy of this report was provided to the facility.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Talwinder Bains
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

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