340317817-3-9-2021-27-AS-KHOS-BYZRBF-20210311115239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 340317817
Report Date: 03/09/2021
Date Signed: 03/09/2021 05:31:31 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
08/20/2020 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20200820101846

FACILITY NAME:	CLEGG CARE FACILITY		FACILITY NUMBER:	340317817
ADMINISTRATOR:	CLEGG, EDNA S		FACILITY TYPE:	740
ADDRESS:	7249 CARMI STREET		TELEPHONE:	(916) 429-6444
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	10	CENSUS: 10	DATE:	03/09/2021
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Edna Clegg		TIME COMPLETED:	05:16 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility has bed bugs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021

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 5

Control Number 27-AS-20200820101846

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: CLEGG CARE FACILITY	FACILITY NUMBER: 340317817
	VISIT DATE: 03/09/2021

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

The preponderance of evidence standard has been met; therefore, the above allegations are found to be
substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of
Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were
provided. Exit interview was conducted with Administrator. Copy of the report sent to Licensee via e-mail
with a "read receipt" to verify the LIC 9099, LIC 9099-D, and appeal rights were received. Licensee is to
print out each report, sign it, and send a signed copy to LPA at 916-263-4744

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 27-AS-20200820101846

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: CLEGG CARE FACILITY	FACILITY NUMBER: 340317817
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/09/2021 Section Cited CCR 80087(a)(1)	1 2 3 4 5 6 7	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. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee has disposed of the old furniture and flooring through a County dump pickup, Licensee already called an exterminator company to conduct an inspection to show proof that the facility no longer has any traces of bedbugs in the facility on 02/22/2021
	8 9 10 11 12 13 14	Based on interviews and evidence received. bed bugs were reported in the facility by service coordinator from agnecy. Facility has been privately treated for bedbugs by Licensee. This poses a potential health risk to the persons in care.	8 9 10 11 12 13 14	Administrator will send copy of invoice from the exterminator company to show that the facility inspection was completed via email to LPA no later than 03/15/2021
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
08/20/2020 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20200820101846

FACILITY NAME:	CLEGG CARE FACILITY		FACILITY NUMBER:	340317817
ADMINISTRATOR:	CLEGG, EDNA S		FACILITY TYPE:	740
ADDRESS:	7249 CARMI STREET		TELEPHONE:	(916) 429-6444
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	10	CENSUS: 10	DATE:	03/09/2021
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Edna Clegg		TIME COMPLETED:	05:16 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

staff did not prevent resident from wandering away from the facility.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Anthony Tuck contacted Licensee by phone to deliver findings to a complaint investigation on 03/09/2021. Findings are being delivered by phone due to current COVID-19 precautionary measures in place.
The allegation is the staff did not prevent resident from wandering away from the facility.
LPA conducted interviews with Licensee and reviewed copy of LIC 624 and LIC 602. LPA reviewed copy of statements from Licensee. LPA reviewed copy of County Coroner report of former resident. Based upon review of documents and interviews, LIC 602 indicated the resident is permitted to leavethe facility unassisted.
The Department (CCLD) has found the allegation of staff not preventing resident from wandering away from the facility, Unsubstantiated. A finding that the complaint allegation(s) is
UNSUBSTANTIATED means that although the allegation(s) may have happened or is valid, there is not a
preponderance of the evidence to prove that the alleged violation(s) occurred. Exit interview was conducted with Edna Clegg. Copy of the report sent toEdna via e-mail with a "read receipt" to verify the LIC 9099 was received. Edna is to print out the report,sign it, and fax a signed copy to LPA at 916-263-4744.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
08/20/2020 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20200820101846

FACILITY NAME:	CLEGG CARE FACILITY		FACILITY NUMBER:	340317817
ADMINISTRATOR:	CLEGG, EDNA S		FACILITY TYPE:	740
ADDRESS:	7249 CARMI STREET		TELEPHONE:	(916) 429-6444
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	10	CENSUS: 10	DATE:	03/09/2021
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Edna Clegg		TIME COMPLETED:	05:16 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

staff did not file the missing person report with proper authorities.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Anthony Tuck contacted Licensee by phone to deliver findings to a complaint investigation on 03/09/2021. Findings are being delivered by phone due to current COVID-19 precautionary measures in place.
The allegation is the staff did not file the missing person report with proper authorities.
LPA conducted interviews with RP and Licensee. LPA reviewed copy of Missing person report from Sacramento County Sheriff's office. LPA learned the date of the missing person report was filed on the same date the resident went missing.
This agency has investigated the allegation listed above. We have found that the complaint was unfounded,
meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have
therefore dismissed the complaint. Exit interview was conducted with Edna Clegg. Copy of the report sent to
Edna via e-mail with a "read receipt" to verify the LIC 9099 was received. Edna is to print out the report,
sign it, and fax a signed copy to LPA at 916-263-4744.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (209) 242-5200
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 5