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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312701001
Report Date: 03/08/2022
Date Signed: 03/08/2022 02:43:33 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/01/2021 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20211101110835
FACILITY NAME:A1 SENIOR CARE 2FACILITY NUMBER:
312701001
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:2040 SYMPHONY AVETELEPHONE:
(916) 472-4543
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ezra Ternate, Caregiver and Jocelyn Javelana, CaregiverTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not following Covid-19 protocols
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced on 03/08/2022 to conduct a Complaint Investigation Visit to deliver the results of the allegation above. LPAs conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPAs were screened by Caregiver.

LPA Hiratsuka, investigated the allegation “Staff are not following Covid-19 protocols.” LPA Hiratsuka, interviewed Administrator Daisyree Tacandong, over the phone on a previous date. Administrator stated one time there were a couple of visitors to this facility that did not wear masks, which is mandated per the State of California. Since then, staff have been instructed to ensure all visitors and staff wear masks while in the facility until or if the mandate is lifted. There is a sign on the the front door that requires all staff and visitors to wear masks.
Based on the above, the allegation is substantiated. Deficiency is cited on 9099-D, per Title 22 Regulations, Division 6. Appeal rights were provided to the caregiver on duty.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/01/2021 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20211101110835

FACILITY NAME:A1 SENIOR CARE 2FACILITY NUMBER:
312701001
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:2040 SYMPHONY AVETELEPHONE:
(916) 472-4543
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ezra Ternate, Caregiver and Jocelyn Javelana, CaregiverTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff are not taking universal precautions
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced on 03/08/2022 to conduct a Complaint Investigation Visit to deliver the results of the allegation above. LPAs conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPAs were screened by Caregiver.

LPA Hiratsuka, investigated the allegation “Staff are not taking universal precautions.” LPA Hiratsuka, interviewed Administrator Daisyree Tacandong, over the phone on a previous date. LPAs interviewed the two staff on duty, LPA Calzado, opened this complaint and interviewed some people on 11/03/2021. This allegation concerned the way staff cleaned up after cooking. It was alleged the staff did not clean hands or change gloves between cleaning and cooking. Staff deny this occurring. Complainant stated that person and another saw the incident occur once. Resident interviewed today stated that does not happen.
LPAs cannot prove or disprove the incident occurred. Allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/01/2021 and conducted by Evaluator Kerry Hiratsuka
COMPLAINT CONTROL NUMBER: 25-AS-20211101110835

FACILITY NAME:A1 SENIOR CARE 2FACILITY NUMBER:
312701001
ADMINISTRATOR:TACANDONG, DAISYREEFACILITY TYPE:
740
ADDRESS:2040 SYMPHONY AVETELEPHONE:
(916) 472-4543
CITY:ROSEVILLESTATE: CAZIP CODE:
95747
CAPACITY:6CENSUS: 6DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Ezra Ternate, Caregiver and Jocelyn Javelana, CaregiverTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not meeting dietary requirements for residents
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Kerry Hiratsuka and Lavinia Muscan arrived at the facility unannounced on 03/08/2022 to conduct a Complaint Investigation Visit to deliver the results of the allegation above. LPAs conducted COVID-19 Precautionary prescreening, and wore a surgical mask while at facility. LPAs were screened by Caregiver.
LPA Hiratsuka, investigated the allegation “Staff do not meeting dietary requirements for residents” LPA Hiratsuka, interviewed Administrator Daisyree Tacandong, over the phone on a previous date. It was alleged the facility served boxed macaroni and cheese and donuts. This is not a violation of the regulations unless the resident does not want it or the resident is on a restricted diet. A check of the files today indicates one resident is diabetic and it is being monitored and does not specify any foods the resident may not eat. The resident is also mentally capable of making their own decisions when it comes to food. The foods in the facility range from fresh to nonperishable. All cater to the likes of the residents. “This agency has investigated the complaint alleging; Staff do not meeting dietary requirements for residents. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 25-AS-20211101110835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: A1 SENIOR CARE 2
FACILITY NUMBER: 312701001
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2022
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: A couple of
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By 03/09/2022, Licensee stated she posted a sign on the door, everyone is told to wear one and masks are provided upon entrance. She is going to email LPA the mask policy.
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 A couple of visitors were not wearing masks in the facility per the CA Public Health Mandate. This poses an immediate threat to residents in care.
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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: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4