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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340317807
Report Date: 05/17/2023
Date Signed: 05/17/2023 10:22:14 AM

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
05/01/2023 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230501100240
FACILITY NAME:ALLEN'S CARE HOMEFACILITY NUMBER:
340317807
ADMINISTRATOR:ALLEN, MELVINAFACILITY TYPE:
735
ADDRESS:3701 KNIGHTLINGER STREETTELEPHONE:
(916) 922-9211
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY:6CENSUS: 6DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Willy AllenTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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The facility does not have a current administrator.
Facility is not maintaining clients' P&I records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 05/17/2023 at 8:30 AM to deliver complaint findings, LPA met with Willy Allen and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed document files. It was learned the facility Administrator Certificate expired on February 23, 2023. The facility Administrator has not submitted their recertification administrator documentation to Administrator Certification Section (ACS). As a result, the facility does not have a current Administrator. Additionally, the facility has designated an Administrator, however, Community Care Licensing Department (CCLD) has not received all requested documents to complete the Administrator change. LPA Martinez has requested the following: LIC 200 Application requesting administrator change; LIC 503 Health Screening Report; LIC 500 Personnel Report. All documents are due by May 22, 2023 by 5 PM.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
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 3
Control Number 27-AS-20230501100240
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: ALLEN'S CARE HOME
FACILITY NUMBER: 340317807
VISIT DATE: 05/17/2023
NARRATIVE
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Moreover, during May 1, 2023 initial complaint visit, LPA Martinez requested to review P&I documentation, however, the documentation was not at the facility. The Licensee reported the documents were not at the facility and at their home. The files were relocated due to fact the Licensee was updating the files with new information. During May 17, 2023 facility visit, the P&I files were at the facility. LPA Martinez reviewed the P&I files, and the P&I documentation does not have May of 2023 P&I Ledgers for all clients in care. In addition, LPA Martinez requested current Surety Bond documentation, which should be emailed to LPA Martinez by May 23, 2023 5 PM.

Due to this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20230501100240
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: ALLEN'S CARE HOME
FACILITY NUMBER: 340317807
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2023
Section Cited
CCR
85064(a)(b)
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85064 (a)(b) Administrator Qualifications and Duties: In addition to Section 80064, the following shall apply...All adult residential facilities shall have a certified administrator.
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The Licensee agrees to appoint a qualified Administrator and submit new Administrator documentation by POC date 05/23/23 by 5 PM.
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This requirement was not met as evidence by: Based on observation and file review, the Administrator's Certificate expired on 02,23,23. This posed a potential health and safety risk for clients in care.
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Type B
05/22/2023
Section Cited
CCR
80026(h)
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80026 (h) Safeguards for Cash Resources, Personal Property, and Valuables of Residents: Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care... This requirement was not met as evidence by:
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The Licensee agrees to email surety bond and May 2023 P&I documentation by POC date 05/2/23/23 by 5 PM. P&I training has been conducted for staff.
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Based on observation and file review the Licensee did not ensure clients P&I records were maintained and in the facility for review. This posed a potential health and safety risk for clients 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: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Avelina Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3