317001644-1-14-2025-59-AS-KHOS-DD4LX2-20250120080801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 317001644
Report Date: 01/14/2025
Date Signed: 01/14/2025 04:35:19 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
12/13/2024 and conducted by Evaluator Graham Gunby

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20241213093239

FACILITY NAME:	MARCELLA GREEN FAMILY HOME		FACILITY NUMBER:	317001644
ADMINISTRATOR:	GREEN, LIN		FACILITY TYPE:	735
ADDRESS:	11742 JONES STREET		TELEPHONE:	(530) 863-8866
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	6	CENSUS: 3	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Licensee, Marcella Green		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility is not clean, safe, sanitary
Personal Rights.

INVESTIGATION FINDINGS:

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LPA Graham Gunby and LPMs Laura Munoz and Troy Ordonez conducted a complaint investigation to this facility to day. CCL staff me with Marcella Green and explained the purpose of today’s visit.
The department has learned that the facility has mold in multiple areas of the facility. A mold sample has been taken from this facility and identified the facility has elevated levels of fungal spores which have been noted as airborne, toxic and may cause serious health risk. In addition, during today’s visit, LPA and LPM observed debris in the yard of the facility as well as a glass paneling removed from the oven in the kitchen. Based on observations and documents reviewed, the licensee failed to ensure the facility is kept clean, safe and sanitary.
Due to the toxic airborne mold, the facility has failed to ensure resident’s personal rights are maintained as residents have a right to safe and helpful accommodations.

Based on information obtained during the investigation, the Department find the allegation to be SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC9099-D. Failure to correct deficiencies could result in civil penalties.

Appeal rights provided
//Exit interview conducted

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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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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
12/13/2024 and conducted by Evaluator Graham Gunby

PUBLIC

COMPLAINT CONTROL NUMBER: 59-AS-20241213093239

FACILITY NAME:	MARCELLA GREEN FAMILY HOME		FACILITY NUMBER:	317001644
ADMINISTRATOR:	GREEN, LIN		FACILITY TYPE:	735
ADDRESS:	11742 JONES STREET		TELEPHONE:	(530) 863-8866
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	6	CENSUS: 3	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Licensee, Marcella Green		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Hygiene supplies not readily available to clients
Linens, blankets, and towels in poor condition
Inadequate supply of perishable and non-perishable food

INVESTIGATION FINDINGS:

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LPA Graham Gunby and LPMs Laura Munoz and Troy Ordonez conducted a complaint investigation to this facility to day. CCL staff me with Marcella Green and explained the purpose of today’s visit.

During today’s visit, LPA and LPM toured the facility and observed the following:
• The facility has sufficient hygiene items for residents in care
• Linen blankets were observed to be clean and readily available to clients in care
• There is an adequate amount of food. LPA and LPMs did not observe any expired or rotten food.

Based on the observations conducted, the complaint is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are UNSUBSTANTIATED.

No deficiencies cited.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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 59-AS-20241213093239

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: MARCELLA GREEN FAMILY HOME	FACILITY NUMBER: 317001644
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/22/2025 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.	1 2 3 4 5 6 7	Per ACRC, (3) three residents who reside at this facility are being relocated today, 01/14/2025. The licensee has been advised that no other resident's shall be admitted to this facility until the licensee has provided the department with documentation that the toxic mold has been removed.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Mold samples have determined that toxic airborne mold has been identified in the facility which is an immediate health and safety risk to resident's in care.	8 9 10 11 12 13 14
Type A 01/15/2025 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	80072 Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.	1 2 3 4 5 6 7	Per ACRC, (3) three residents who reside at this facility are being relocated today, 01/14/2025. The licensee has been advised that no other resident's shall be admitted to this facility until the licensee has provided the department with documentation that the toxic mold has been removed.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Mold samples have determined that toxic airborne mold has been identified in the facility which is an immediate health and safety risk to resident's in care.	8 9 10 11 12 13 14

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: Troy Ordonez
LICENSING EVALUATOR NAME: Graham Gunby
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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