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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 312701032
Report Date: 01/02/2025
Date Signed: 01/02/2025 03:44:46 PM

Substantiated


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
08/19/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240819102848
FACILITY NAME:AMI HOUSING, INC.FACILITY NUMBER:
312701032
ADMINISTRATOR:JENNIFER PRICEFACILITY TYPE:
735
ADDRESS:1720 LILAC LANETELEPHONE:
(530) 878-5088
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:15CENSUS: 14DATE:
01/02/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Brooke Hegel, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is not providing adequate care and supervision to clients

Facility staff are not adequately trained

Facility is not providing adequate food services to clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Brooke Hegel, to deliver findings into the complaint allegations listed above.

During the investigation, LPA toured the facility, conducted interviews, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Facility is not providing adequate care and supervision to clients

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
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 7
Control Number 59-AS-20240819102848
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: AMI HOUSING, INC.
FACILITY NUMBER: 312701032
VISIT DATE: 01/02/2025
NARRATIVE
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During the investigation, LPA received a "Three Day Notice to Perform Conditions and/or Covenants or Quit" authored by the facility in relation to resident (R1). The notice states: "10/06/2024 When Resident [R1] returned to the facility from an outing with [relevant party], [R1] began spraying disinfectant around the facility. [R1] sprayed disinfectant spray onto two other housemates that were sitting on the couch in the common area watching TV. AMIH Staff could visibly see the amount of disinfectant spray in the air that surrounded the housemates. The housemates politely asked that [R1] stop spraying the disinfectant."

During the investigation, LPA received an Unusual Incident/Injury Report (SIR) dated 10/09/2024 indicating that "On 10/06/2024, at approximately 6 PM, resident [R1] sprayed disinfectant spray onto two other residents." During visit conducted on 11/13/2024, LPA observed storage for disinfectants and cleaning products to be unlocked and accessible to the residents in care.

Allegation: Facility staff are not adequately trained

LPA reviewed facility's Plan of Operation on file with the Department. Facility's Plan of Operation states the following: "All employees are required to obtain 40 hours of training per year. This training includes a combination of internal and external training opportunities including options offered by our local County of Placer. For all new employees, we mandate a New Employee Orientation and trainings focused on understanding the client populations, understanding the agency documentation policy and procedure, all agency programs and services, CCL requirements, service coordination techniques, APS reporting procedures and safety procedures. All staff receive training on signs of abuse, including but not limited to, physical, emotional and financial and are trained on Mandated Reporting. Staff are expected to report any concerns of abuse to their manager and complete an APS report when needed."

LPA reviewed documentation for staff training kept at the facility for staff members S1, S2, S3, and S4. LPA observed that S1 received 9.5 hours of training from Relias Learning and 8 trainings without documentation of hours completed for the year of 2024. LPA observed that S2 received 9.5 hours of training from Relias Learning and 11 trainings without documentation of hours completed for the year of 2024.

** Report continued on 9099-C **
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20240819102848
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: AMI HOUSING, INC.
FACILITY NUMBER: 312701032
VISIT DATE: 01/02/2025
NARRATIVE
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LPA observed that S3 received 12.5 hours of training from Relias Learning, 4 hours from CPR and first aid, and 1 training without documentation of hours completed for the year of 2024. LPA observed that S4 received 8 hours of training from Relias Learning and 8 trainings without documentation of hours completed for the year of 2023. LPA observed that S4 received 1.25 hours of training from Relias Learning for the year of 2024. No other training documentation could be provided to LPA at the conclusion of the investigation in relation to S1, S2, S3, and S4.

Allegation: Facility is not providing adequate food services to clients

Relevant party reported that facility was not providing R1 with food belonging to R1's prescribed modified diet. LPA reviewed R1's Physician's Report LIC 602 dated 7/18/2023, which indicates that R1 has a special diet of "modified Mediterranean." Interviews conducted with S1, S2, S3, and S4 indicated that R1 was eating meals that belonged to R1's modified Mediterranean diet. During the investigation, LPA observed food items on the premises that belonged to R1's modified Mediterranean diet.

During visit conducted on 8/21/2024, LPA observed multiple food items at the facility to be expired. Licensee removed the expired food items from the premises during LPA's inspection. During all subsequent visits over the course of the investigation, LPA did not observe expired food items on the premises. As a result of LPA's initial visit to the facility, LPA determines that the facility was not providing adequate food services prior to visit conducted on 8/21/2024.

Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with Administrator. A copy of this report and appeal rights were provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 59-AS-20240819102848
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: AMI HOUSING, INC.
FACILITY NUMBER: 312701032
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/03/2025
Section Cited
CCR
80087(g)
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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Facility will ensure that disinfectants and cleaning solutions are inaccessible to the residents in care at all times. Facility will complete a statement of understanding regarding regulation 80087 and submit statement to LPA by POC due date of 1/3/2025.
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Based on LPA's observations and records reviewed, the facility did not ensure proper supervision when disinfectants were accessible to the residents in care, which poses an immediate health, safety, and personal rights risk to the residents in care.
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Type B
01/17/2025
Section Cited
CCR
80022(k)
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80022 Plan of Operation (k) The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. This requirement is not met as evidenced by:
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Facility will ensure to complete training for all staff in accordance with the facility's Plan of Operation. Facility will complete a statement of understanding regarding regulation 80022 and submit statement to LPA by POC due date of 1/17/2025.
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Based on LPA's observations and records reviewed, the facility did not ensure staff were receiving training in accordance with facility's Plan of Operation, which poses a potential health, safety, and personal rights risk to the 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20240819102848
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: AMI HOUSING, INC.
FACILITY NUMBER: 312701032
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/17/2025
Section Cited
CCR
80076
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. (...) This requirement is not met as evidenced by:
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Facility will ensure that all food items on the premises are of good quality. LPA did not observe any expired food items on the premises during all subsequent visits following initial visit. LPA cleared deficiency at the conclusion of this investigation.
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Based on LPA's observations, the facility did not ensure to have food items that were safe and of good quality when there were multiple expired food items on the premises, which poses a potential health, safety, and personal rights violation to the 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.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
08/19/2024 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 59-AS-20240819102848

FACILITY NAME:AMI HOUSING, INC.FACILITY NUMBER:
312701032
ADMINISTRATOR:JENNIFER PRICEFACILITY TYPE:
735
ADDRESS:1720 LILAC LANETELEPHONE:
(530) 878-5088
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:15CENSUS: 14DATE:
01/02/2025
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Brooke Hegel, AdministratorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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2
3
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Facility is not safeguarding the confidentiality of client information

Facility staff are not communicating with clients’ authorized representative regarding client’s care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Brooke Hegel, to deliver findings into the complaint allegations listed above.

During the investigation, LPA toured the facility, conducted interviews, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows:

Allegation: Facility is not safeguarding the confidentiality of client information

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20240819102848
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: AMI HOUSING, INC.
FACILITY NUMBER: 312701032
VISIT DATE: 01/02/2025
NARRATIVE
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Relevant party reported that the facility was not safeguarding client information when emailing relevant party information pertaining to a resident in care. LPA reviewed email correspondence between relevant party and facility staff. LPA did not observe any individuals attached to emails authored by the facility who were not associated to the facility and did not already have access to the information included in the email correspondence. Interviews with staff members S1, S2, and S4 did not indicate any concerns regarding the safeguarding of client information. No interviews with residents indicated any concerns regarding the safeguarding of client information.

Allegation: Facility staff are not communicating with clients’ authorized representative regarding client’s care

Relevant party reported that the facility were not communicating with a resident's authorized representative. Interviews conducted with staff members S1, S2, S3, and S4 indicated that they were informed to redirect relevant party to the facility's Administrator for information. Interviews with staff did not indicate that they were not communicating with relevant party in general. LPA reviewed email correspondence between relevant party and facility Administrator. LPA observed Administrator to be responding to relevant party's emails.

Based on interviews conducted and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted with Administrator. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Michael Hood
LICENSING EVALUATOR SIGNATURE:

DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/02/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7