312700455-11-30-2023-59-AS-MSEY-CY8TDR-20231205133843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700455
Report Date: 11/30/2023
Date Signed: 11/30/2023 02:25:05 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/03/2023 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20231103163921

FACILITY NAME:	AAA SENIOR CARE		FACILITY NUMBER:	312700455
ADMINISTRATOR:	MICHAEL DEMYAN		FACILITY TYPE:	740
ADDRESS:	1998 CLARK TUNNEL RD		TELEPHONE:	(916) 222-1406
CITY:	PENRYN	STATE: CA	ZIP CODE:	95663
CAPACITY:	6	CENSUS: 5	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Michael Demyan		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff are preventing resident from having visitors
Staff do not answer the facility phone

INVESTIGATION FINDINGS:

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LPA Parks arrived on Thursday November 30, 2023, to conclude a complaint investigation regarding the above allegations.

LPA met with Administrator Michael and explained the purpose of the visit. Throughout the course of the investigation, LPA interviewed R1-R5. Additionally, LPA interviewed POAs for R1-R3.

R’1 POA revealed that they have been having a difficult time assimilating to the facility after moving-in. Per POA, prior to visitors, R1 was engaged, walking, and eating. After a visitor came to the facility, R1 began to refuse to eat and sleep. R1’s POA then asked for their visitors to refrain from visiting until R1 can maintain a healthy routine at the facility. LPA learned that R1 had a visitor when they were sleeping.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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 59-AS-20231103163921

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: AAA SENIOR CARE	FACILITY NUMBER: 312700455
	VISIT DATE: 11/30/2023

NARRATIVE

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The Administrator asked for the visitor to come back on a different day to allow R1 their rest.
LPA interviewed R1-R3’s POAs who revealed that they have not had any difficulty in visiting the facility. Interviews revealed that they were given the gate code upon move-in. Additionally, interviews revealed that staff are responsive to phone calls and texts. The facility has one main line at the facility and two cell phones. All three numbers are given out to POAs, family, and friends of residents.

Based on information obtained during the investigation, LPA finds the allegations to be UNSUBSTANTIATED- a finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred,

Exit interview. A copy of this report was emailed to the Administrator.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC9099 (FAS) - (06/04)

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