<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340317807
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:05:21 PM

Unsubstantiated


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
10/16/2023 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20231016125657
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: 1DATE:
11/03/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Melvina AllenTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA)s Jamie Ivey Canady at the facility unannounced to deliver complaint investigation findings. LPA Ivey Canady explained the purpose of the visit and was met by Melvina Allen.

The investigation was conducted by LPA Ivey Canady. The investigation consisted of interviews with residents, interviews with staff, and review of resident files.

The Department has determined the following as it relates to the allegations: Resident sustained unexplained injuries while in care.

Continued on LIC 9099 - C...
Page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
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-20231016125657
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: ALLEN'S CARE HOME
FACILITY NUMBER: 340317807
VISIT DATE: 11/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 10/20/2023 Licensing Program Analyst (LPA) Jamie Ivey Canady interviewed witnesses regarding current facility allegations. According to witness statements, R1 had sustained an injury that was identified while away from the facility. On 10/23/2023 LPA Ivey Canady interviewed facility staff, R1, and witnesses. During LPA facility visit LPA requested and received facility staff files, resident files and facility resident chart notes and resident medical files. Based on interviews and witness statements, R1 exercised the personal right to refuse showers and all other methods of personal hygiene. According to medical documentation R1 sustained a bump on the right hand and scratched the bump. It was learned from R1 that R1 kept clothing over the bump after it became a wound and did not alert facility staff. According to facility medical documentation, the bump became infected and turned into a wound. According to facility chart notes, facility staff continuously offered R1 showers and attempted to assist R1 with personal hygiene and was refused. Based on LPA investigation, facility staff was unaware of R1 having sustained a wound because R1 kept the wound covered and declined assistance with showering and personal hygiene. Therefore, the allegation Resident sustained unexplained injuries while in care is Unsubstantiated.
An unsubstantiated finding means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was given to Administrator Melvina Allen.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4