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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340317817
Report Date: 07/18/2023
Date Signed: 07/18/2023 03:26:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
07/10/2023 and conducted by Evaluator Pang Lee
COMPLAINT CONTROL NUMBER: 27-AS-20230710165633

FACILITY NAME:CLEGG CARE FACILITYFACILITY NUMBER:
340317817
ADMINISTRATOR:CLEGG, EDNA SFACILITY TYPE:
740
ADDRESS:7249 CARMI STREETTELEPHONE:
(916) 429-6444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:10CENSUS: 7DATE:
07/18/2023
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Edna ClaggTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility shower is hazardous.
Facility is not ensuring that residents are provided toilet paper.
INVESTIGATION FINDINGS:
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On 07/18/2023 at 8:00 AM, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced facility visit to open a complaint investigation. LPA met with Licensee Edna Clegg and explained the purpose of today's visit.

During today's visit, LPA Lee conducted 6 out of 7 resident interviews. It was learned that one resident is out visiting family memebers. 6 out of 6 residents had no concerns regarding facility shower being hazardous and facility staff not ensuring that residents are being provided with toilet paper. Based on LPA Lee observations, at At 9:30 AM, LPA Lee toured the facility bathroom #1 and bathroom #2, LPA Lee observed both bathroom in good working condition. LPA Lee did not observed any hazardous in both bathroom showers. LPA Lee also observed both bathroom having two toilet paper rolls ontop of the toilet.

As a result, the allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Continued LIC 9099 C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20230710165633
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: CLEGG CARE FACILITY
FACILITY NUMBER: 340317817
VISIT DATE: 07/18/2023
NARRATIVE
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The Department has determined that the allegations facility shower is hazardous and facility is not ensuring that resident are provided toilet paper are unsubstantiated.

An exit interview was conducted with Licensee Edna Clegg, and a copy of this report was provided to the facility at the end of this visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7