577000960-11-12-2021-21-AS-KMOA-C92RJL-20211123120408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 577000960
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:22:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2021 and conducted by Evaluator Jill Nakagawa

COMPLAINT CONTROL NUMBER: 21-AS-20210409152055

FACILITY NAME:	GLORIA'S COUNTRY CARE		FACILITY NUMBER:	577000960
ADMINISTRATOR:	JOSE L GARCIA		FACILITY TYPE:	740
ADDRESS:	34606 HIGHWAY 16		TELEPHONE:	(530) 668-8444
CITY:	WOODLAND	STATE: CA	ZIP CODE:	95695
CAPACITY:	23	CENSUS:	DATE:	11/12/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Lupe Castallenos/Alma Peniche		TIME COMPLETED:	03:21 PM

ALLEGATION(S):

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Facility does not have adequate telephone service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Nakagawa arrived at Gloria’s Country Care Facility on 11/12/2021 for the purpose of delivering findings on complaint # 21-AS-20210409152055. LPA met with Lupe Castallenos (in person) and Alma Peniche, Administrative Assistant via telephone.
LPAs Canela and LPA Arnhold investigated the allegations of “Facility did not ensure residents are able to receive or make calls” and "Facility does not have adequate telephone service". During the investigation, LPAs conducted interviews with staff and residents, obtained and reviewed records, reviewed the facility file, inspected the facility virtually and in-person.

Report continued see LIC9099-C…

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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 21-AS-20210409152055

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GLORIA'S COUNTRY CARE	FACILITY NUMBER: 577000960
	VISIT DATE: 11/12/2021

NARRATIVE

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LIC 9099 (2)

complaints of missed calls which is the reason behind having staff use their cell phones. Administrator and facility staff indicated the facility phone landline in the past did not work out well because staff could not hear the phone ring or answer the phone because they were tending to the residents, and the facility is located in a marsh area resulting in bad phone service with a landline phone. However, the facility staff’s cell phones will have service at the facility.

Based on LPA’s observations, interviews conducted with staff and resident’s responsible parties and record review which concluded Gloria’s Country Care (GCC) does not have a facility phone on the premises dedicated for residents to make and receive confidential phone calls. The preponderance of evidence standard has been met, therefore the allegations of “Facility did not ensure residents are able to receive or make calls” and “Facility does not have adequate telephone service” is found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D document.

Exit interview conducted with Maria Guadalupe for , whose signature below confirms receipt of this document.

Appeal Rights Provided.
Deficiencies (on the attached LIC9099D) are being cited from the California Code of Regulations, Title 22, Division 6.
Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210409152055

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GLORIA'S COUNTRY CARE	FACILITY NUMBER: 577000960
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/12/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/16/2021 Section Cited CCR 87468.1(a)(14)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a)Residents ... shall have ... the following personal rights: (14)To have reasonable access to telephones, to both make and receive confidential calls... This requirement was not met at evidenced by:	1 2 3 4 5 6 7	Licensee to submit a plan of how they will ensure the regulation and written statement they understand the requirement and will be in future compliance with the regulation 87468.1(a)(14) by POC due date 11/16/2021 to Community Care Licensing attention LPA Nakagawa in order to clear the citation
	8 9 10 11 12 13 14	Based on observations, record review, and interviews conducted: Administrator did not ensure the regulation above due to not having a facility phone on site for residents to make confidential calls This is a potential personal rights risk to the residents in care.	8 9 10 11 12 13 14
Type B 11/16/2021 Section Cited CCR 87311	1 2 3 4 5 6 7	87311 Telephones: All facilities shall have telephone service on the premises. This requirement was not met at evidenced by:	1 2 3 4 5 6 7	Licensee to submit a plan of how they will ensure the regulation and written statement they understand the requirement and will be in future compliance with the regulation 87311 by POC due date 11/16/2021 to Community Care Licensing attention LPA Nakagawa in order to clear the citation
	8 9 10 11 12 13 14	Based on observations, record review, and interviews conducted: Administrator did not ensure the regulation above due to not having a facility telephone service on the facility premises as required. This is a potential personal rights risk to the residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Jill Nakagawa	TELEPHONE: 707-588-5063
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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