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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340308207
Report Date: 04/08/2024
Date Signed: 04/08/2024 11:27:54 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
04/05/2024 and conducted by Evaluator Vincent Moleski
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240405101732
FACILITY NAME:SACRAMENTO GUEST HOMEFACILITY NUMBER:
340308207
ADMINISTRATOR:MANGABAT, NORMINIOFACILITY TYPE:
740
ADDRESS:2715 G ST.TELEPHONE:
(916) 447-1502
CITY:SACRAMENTOSTATE: CAZIP CODE:
95816
CAPACITY:13CENSUS: 11DATE:
04/08/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gladys MangabatTIME COMPLETED:
11:30 PM
ALLEGATION(S):
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Resident was served unlawful eviction notice
Facility is in disrepair
Facility is unclean
Waste was stored in an unsafe manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open this complaint investigation. LPA Moleski met with facility administrator Gladys Mangabat and explained the purpose of the visit.

LPA Moleski reviewed this facility's house rules and an eviction notice for R1. The eviction notice stated that R1 was being evicted effective as of 4/4/24 due to marijuana use and inappropriate behaviors, including arguing with roommates. The notice did not contain a sufficient amount of detail, such as time and dates, nor did it contain the required information about unlawful detainers, nor did it contain information about residents' rights to file a complaint, nor did it contain contact information for CCLD, and therefore was not lawful.

LPA Moleski toured this facility. LPA Moleski and Mangabat observed in the ktichen a dish on the floor containing chicken scraps. Mangabat said it was for her dog. LPA Moleski and Mangabat observed an uncovered container on the counter containing waste. Mangabat said it was compost, and covered the container. [continued on 9099-C]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
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 27-AS-20240405101732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: SACRAMENTO GUEST HOME
FACILITY NUMBER: 340308207
VISIT DATE: 04/08/2024
NARRATIVE
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LPA Moleski and Mangabat observed rodent droppings on the carpet in a resident's room. LPA Moleski and Mangabat observed in this same resident bedroom a mattress with what appeared to be feces stains on it.

LPA Moleski and Mangabat observed in all resident bathrooms uncovered waste bins containing toilet paper soiled by what appeared to be feces. LPA Moleski and Mangabat observed damage to moulding in one of these bathrooms that was broken. Pieces of the moulding were observed broken and lying on the floor. The bathroom floor near the broken moulding was covered in a brownish colored, moist substance. Mangabat said there may be a soap leak.

LPA Moleski observed the back patio to be in reasonably good condition and did not appear to be in disrepair.

The department has determined the following as it relates to the allegations that a resident was served an unlawful eviction notice, that the facility is in disrepair, that the facility is unclean, and that waste was stored in an unsafe manner:

Based on observation and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met.

This facility is being cited per 22 CCR Sections 87224(d)(1)(B-D), 87470(a)(2)(D), and 87303(a). An exit interview was held with Mangabat. Appeal rights and a copy of this report were left with Mangabat.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 27-AS-20240405101732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SACRAMENTO GUEST HOME
FACILITY NUMBER: 340308207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2024
Section Cited
CCR
87224(d)(1)(B-D)
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"(1) The notice to quit shall include the following information:
...
(B) Resources available to assist in identifying alternative housing and care options which include, but are not limited to, the following:

1. Referral services that will aid in finding alternative housing.

2. Case management organizations which help manage individual care and service needs.
(C) A statement informing residents of their right to file a complaint with the licensing agency, as specified in Section 87468, subsection (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office.

(D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing."
This requirement was not met as evidenced by:
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Licensee agrees to write a letter to R1 and R1's responsible party notifying them that this eviction notice is no longer in effect. Licensee shall send LPA Moleski a copy of the letter.
vincent.moleski@dss.ca.gov
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Based on record review, licensee served an unlawful eviction notice, which poses a potential health, safety, and/or personal rights risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240405101732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SACRAMENTO GUEST HOME
FACILITY NUMBER: 340308207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
CCR
87303(a)
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"(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors."
This requirement was not met as evidenced by:
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Licensee agrees to clean the facility and obtain repair services by the POC due date. Licensee shall provide photos to LPA Moleski afterward.
vincent.moleski@dss.ca.gov
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Based on observation, the facility was not clean in a resident's room and in the kitchen, and, in addition, one facility bathroom was in disrepair, which poses an immediate health and safety risk.
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Type A
04/09/2024
Section Cited
CCR
87470(a)(2)(D)
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"(D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission."
This requirement was not met as evidenced by:
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Licensee agrees to remove the bins and instruct residents to flush soiled toilet paper down the toilet by POC due date. Licensee agrees to put up signs in bathrooms to this effect.
vincent.moleski@dss.ca.gov
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Based on observation, hazardous waste capable of spreading disease, i.e. feces, was kept in an uncovered container in facility bathrooms, which poses an immediate health and safety risk.
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent MoleskiTELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4