340317173-4-12-2021-27-AS-SRIN-C22V5R-20210413160823

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340317173
Report Date: 04/12/2021
Date Signed: 04/12/2021 01:31:50 PM

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
09/04/2020 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20200904163256

FACILITY NAME:	DOSTY'S PRIVATE INCARE SEVICES II		FACILITY NUMBER:	340317173
ADMINISTRATOR:	JANAE D ROSS		FACILITY TYPE:	735
ADDRESS:	6924 SOUTH LAND PARK DRIVE		TELEPHONE:	(916) 399-8109
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 4	DATE:	04/12/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Janae Ross		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
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9

Staff yelled at client.
Staff got into a physical altercation with client.
Staff damaged clients personal property.

INVESTIGATION FINDINGS:

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2
3
4
5
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9
10
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13

Licensing Program Analyst Victoria Brown conducted a televisit on 4/12/21 at 1pm due to Covid-19 and precautionary measure. This visit is to conclude the investigation and deliver findings. LPA met with Janae Ross, Administrator regarding the purpose of todays visit.
An Incident Report and Complaint was received by Community Care Licensing on 9/3/2020 indicating that on 9/2/2020 Staff #1 was engaged in an altercation with resident #1 over possible negative verbage stated against R1's responsible party. LPA interviewed R1 on 4/11/21. The statements during the interview was not consisitent with the information obtained from the Incident report and the complaint. According to R1 there were no objects such as a broom or a chair involved and there were no other staff at the facility. Police were called but there was no report made by either parties. R1 sustained scratches but it is unclear if it happened during the time R1 was removing clothing in an angry state. LPA was unable to interview staff 1,2,4 and resident 2-3. Staff # 3 could not corroborate the incident and denied taking any pictures of R1. In regards to R1's personal property, this was a separate incident involving R2 and R3 and a different staff that accidentally bumped into R1's tv and broke the screen. However, since then the tv has been replaced.
The investigation revealed that based on interviews and documentation the allegations are UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubtantiated. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. An exit interview was held and a copy of this report was provided via email. An electronic email read receipt confirms receiving these documents.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021

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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