312700808-10-5-2022-25-AS-KHOS-CMLNNJ-20221230093647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 312700808
Report Date: 10/05/2022
Date Signed: 10/05/2022 10:19:07 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2022 and conducted by Evaluator Melissa Parks

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220927075627

FACILITY NAME:	PACIFIC COAST CARE HOMES		FACILITY NUMBER:	312700808
ADMINISTRATOR:	ZAIDI, MARIA		FACILITY TYPE:	740
ADDRESS:	4470 ROLLING OAKS DRIVE		TELEPHONE:	(916) 823-3902
CITY:	GRANITE BAY	STATE: CA	ZIP CODE:	95746
CAPACITY:	6	CENSUS: 6	DATE:	10/05/2022
		UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Oscar De La Rosa		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff living in garage

INVESTIGATION FINDINGS:

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LPA Parks arrived on Wednesday October 5, 2022 to open a complaint investigation regarding the above allegation. Prior to the visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; LPA ensured she applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask.

LPA spoke with Maria over the phone regarding the allegations. LPA interviewed the staff who were on shift at the facility. As LPA and Staff Oscar were entering the garage, LPA observed a staff member, later identified as Alex, leaving the garage. LPA observed the following items in the garage: full bed, dresser, shoe rack filled with shoes, personal items, additional bedding, dresser filled with clothes, television, hats, and various food/drink. Based on observation, LPA has concluded that the allegation is true.

Substantiated

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: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 25-AS-20220927075627

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PACIFIC COAST CARE HOMES	FACILITY NUMBER: 312700808
	VISIT DATE: 10/05/2022

NARRATIVE

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As a result of this investigation, the Department finds the allegation to be Substantiated.
A finding that the complaint is Substantiated means that the allegation are valid because the preponderance of the evidence standard has been met. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview conducted. Appeal rights were given. A copy of this report was left at the facility.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 25-AS-20220927075627

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: PACIFIC COAST CARE HOMES	FACILITY NUMBER: 312700808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/06/2022 Section Cited CCR 87203	1 2 3 4 5 6 7	Fire Safety 87203: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on evidence of a livable space including furniture	1 2 3 4 5 6 7	Licensee to provide photographic proof that garage is no longer being used as a bedroom for staff
	8 9 10 11 12 13 14	and personal belongings of staff living in the garage.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Maribeth Senty	TELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Melissa Parks	TELEPHONE: (559) 580-5423
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC9099 (FAS) - (06/04)

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