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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 01/02/2025
Date Signed: 01/02/2025 12:23:22 PM

Document Has Been Signed on 01/02/2025 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CLEGG CARE FACILITYFACILITY NUMBER:
340317817
ADMINISTRATOR/
DIRECTOR:		CLEGG, EDNA SFACILITY TYPE:
740
ADDRESS:7249 CARMI STREETTELEPHONE:
(916) 429-6444
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 10CENSUS: 6DATE:
01/02/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:28 AM
MET WITH:Edna CleggTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a case management visit on 01/02/24, at 11:28 AM, LPA Lee met with administrator Edna Clegg and explained the purpose of the visit. The census is 6.

The purpose of today's visit is to follow up on a LIC 624 incident report that the department received on 12/22/24. The incident report is regarding an absent without leave (AWOL) event that occurred on 12/15/24. It was learned that resident 1 (R1) left the facility unassisted at 9:30 AM to attend church and did not return to the facility the entire day. It was also learned that administrator Edna observed R1 signing himself out using the facility sign in and out sheet. Facility staff Maxwell contacted local emergency and law enforcement regarding a missing person. In an interview with facility staff Maxwell, the facility overlooked and didn’t recognize that R1 was unable to leave the premises without assistance. Both Administrator Edna and staff member Maxwell stated that they were unaware of how (R1) ended up at the hospital. In an interview with R1’s Service Coordinator, it was revealed that R1 walked to Walmart after church, where R1 experienced a fall and then a pedestrian helped R1 to Walmart, but upon entering the store, R1 had another fell. Walmart then called an ambulance, and R1 was transported to Methodist Hospital. Furthermore, R1's LIC 602 Physician’s Report, dated 08/12/24, indicates that R1 has mild cognitive impairment and is not capable of leaving the facility unassisted.

Based on today’s case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is assessed on 01/01/25 due to lack of care and supervision and an immediate health and risk to R1. An exit interview was conducted with administrator Edna. A copy of this LIC 809, LIC 809-D, LIC 421-IM and appeal rights was provided to the facility at the end of the visit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 01/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/02/2025 12:23 PM - It Cannot Be Edited


Created By: Pang Lee On 01/02/2025 at 12:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CLEGG CARE FACILITY
FACILITY NUMBER: 340317817

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2025
Section Cited
HSC
1569.312(a)

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1569.312(a) Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.

This requirement is not met as evidence by:
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The Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Licensee/Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended the in-service.
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Based on records review and interviews with the facility staff the facility did not comply with section cited above. R1 left the facility unassisted and did not return to the care home. R1 had a fall and then was transported to the hospital. The LIC 602 states R1 was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.
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Licensee/Administrator will also provide LPA Lee an updated LIC 500 to ensure sufficient staffing at all times and in writing staffing schedule to be put in place immediately to ensure the safety of the residents in care. POC due to LPA Lee by 01/09/2025 end of day 5:00 PM

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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.
SUPERVISOR'S NAME:Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 01/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/02/2025


LIC809 (FAS) - (06/04)
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