312700395-1-25-2021-27-AS-KHOS-BZEJDH-20210324065732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700395
Report Date: 01/25/2021
Date Signed: 01/25/2021 04:54:39 PM

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
05/19/2020 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 27-AS-20200519083110

FACILITY NAME:	A1SENIOR CARE		FACILITY NUMBER:	312700395
ADMINISTRATOR:	TACANDONG, DAISYREE		FACILITY TYPE:	740
ADDRESS:	217 HINGHAM CT		TELEPHONE:	(916) 740-7715
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY:	6	CENSUS: 6	DATE:	01/25/2021
		UNANNOUNCED	TIME BEGAN:	02:59 PM
MET WITH:	Daisyree Tacandong		TIME COMPLETED:	03:29 PM

ALLEGATION(S):

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Facility is not providing food in the quantity necessary to meet the needs of the residents.
Facility is not offering a variety of food for the meals.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kerry Hiratsuka contacted the facility via telephone to deliver the results of complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA discussed the purpose of the call and the elements of the allegation with Daisy Tacando, Administrator.

LPA interviewed two residents who were able to communicate. Both residents stated the food is good and they are happy with it. One resident stated that they aren't able to finish the amount of food served and will sometimes skip a meal. However, if the resident requests food, the staff immediately makes something. LPA observed a lot of snacks in that resident's room and the resident stated they get all the snacks they want. Both stated they are also served a variety of food. Both also stated they do not have any complaints against the facility and are happy.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

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-20200519083110

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: A1SENIOR CARE	FACILITY NUMBER: 312700395
	VISIT DATE: 01/25/2021

NARRATIVE

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LPA and Administrator toured the facility. Administrator showed apples and bananas on the counter, a shopping list of what the caregivers wanted to use to fix meals, the refrigerator and freezer both had vegetables, fruits, and other foods. One of the caregivers on duty was starting to make pineapple upside down cupcakes and had made blueberry banana muffins in the morning. Administrator also showed LPA the cupboard and it was full of a variety of different nonperishable foods.

Based on all the above, the allegations are unfounded.

The allegation is UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

A copy of this report will be provided to the facility administrator via email. A copy will be sent to the facility via email and is to be signed and returned to Community Care Licensing Division.

Signature for facility representative shall be on the hard copy of this report.

SUPERVISOR'S NAME: Troy Ordonez	TELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry Hiratsuka	TELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2021

LIC9099 (FAS) - (06/04)

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