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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340314399
Report Date: 01/23/2023
Date Signed: 01/23/2023 04:14:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2023 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20230113123125
FACILITY NAME:DOSTY'S PRIVATE INCARE SERVICEFACILITY NUMBER:
340314399
ADMINISTRATOR:JANAE ROSSFACILITY TYPE:
735
ADDRESS:7093 CROMWELL WAYTELEPHONE:
(916) 399-1365
CITY:SACRAMENTOSTATE: CAZIP CODE:
95822
CAPACITY:6CENSUS: 4DATE:
01/23/2023
UNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Janae RossTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility is in disrepair.
Facility not clean.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit at this facility on 1/23/23 commence a complaint investigation with the allegations above. LPA met with Administrator Janae Ross and explained the purpose of today’s visit.

During this visit, LPA Truong toured the facility and conducted interviews with the Administrator and residents. On today’s tour of the facility ground, LPA observed the facility was not clean. LPA observed dust and debris on the carpet and throughout the facility. Moreover, LPA observed the air vent in one of the bathrooms was not working. LPA also observed that the toilet in the resident bathroom was not in good repair.

Continued on 9099-D
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
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-20230113123125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: DOSTY'S PRIVATE INCARE SERVICE
FACILITY NUMBER: 340314399
VISIT DATE: 01/23/2023
NARRATIVE
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As a result of this investigation, LPA finds the allegations above 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 cited on the LIC 9099-D, per Title 22 Regulations.

Exit interview was conducted, a copy of the report, LIC 9099-D and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20230113123125
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: DOSTY'S PRIVATE INCARE SERVICE
FACILITY NUMBER: 340314399
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2023
Section Cited
CCR
80087(a)
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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. This requirement is not met as evidence by:
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Licensee/administrator shall ensure the facility are cleaned and in good repair at all times. Licensee/administrator will take pictures once the changes are made and email LPA by POC due date 1/30/2023.
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Based on record and observation, the licensee did not kept the facility clean, sanitary and in good repair at all times. Debris were found on facility ground on 1/23/2023. Toilet and air vent in resident bathroom were not in good repair. This posed a potential, Health, Safety or Personal Rights risk to clients in care.
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The facility will repair or replace the
items listed by the POC date or submit a plan to repair or replace and submit receipts or repair orders by email to CCL by POC due date.
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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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4