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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340317817
Report Date: 03/21/2023
Date Signed: 03/21/2023 10:10:47 AM

Substantiated


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
12/09/2022 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221209110211
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: 9DATE:
03/21/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Edna CleggTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained a shoulder dislocation while in care
INVESTIGATION FINDINGS:
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On 03/21/23 at 9:30 AM, Licensing Program Analysts (LPA) Pang Lee and (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPAs Lee and Martinez met with administrator Edna Clegg who assisted during today’s visit and LPAs explained the purpose of today’s visit.

Throughout the course of this investigation, the Department conducted interviews, reviewed facility files, and reviewed medical documents. It was learned the facility protocol is to leave any fallen residents on the floor until medical professionals arrive. The investigation revealed resident 1 (R1) sustained two falls one on December 03, 2023, and another on December 08, 2023. The two falls were unwitnessed, and it is unknown how long R1 was on the ground. On the December 08, 2023, the facility did not follow their facility fall protocol and procedures. Staff 1 (S1) and staff 2 (S2) admitted to picking up R1 off the ground and transferring R1 to bed. On this day, R1 was sent to the hospital where R1 was diagnosed with a bilateral shoulder dislocation. As a result, the facility did not provide adequate care and supervision, and did not follow facility fall protocol.
Continued...
Substantiated
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: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
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-20221209110211
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: 03/21/2023
NARRATIVE
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Due to R1 sustaining a bilateral shoulder dislocation, the violation warrants civil penalty assessments per Health and Safety Code 1569.49(e). At this time, the civil penalty assessments are under review, and a civil penalty determination is pending by the Department. Once civil penalty assessments have been determined, an LPA will return at a future date to assess the civil penalties.

An immediate $500.00 civil penalty shall be assessed on XXXXX or a violation of California Code of Regulations Section 87464(f)(1), which is based on the allegation: "Resident sustained a shoulder dislocation while in care." which posed an immediate threat to the Health, Safety, and Personal Rights of R1.

As a result of this investigation, the Department finds This allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The deficiency cited can be found on the LIC 9099-D, per Title 22 Regulations.

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

DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20221209110211
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/17/2023
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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Facility staff agree to conduct resident check-ins and document check-in by POC date 03/22/23. Licensing will ensure that Basic Services training is provided for ALL staff. The facility staff agrees to email LPA Lee a written plan in regards to training and how resident check in will be implemented.
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This requirement was not met as evidence by: Based on file review, Observation, and interviews, the Licensee did not ensure R1's basic care needs were being met. This posed an immediate health and safety risk to R1.
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by POC Date 03/21/23 by 5 PM.
All training material and sign in sheet shall be emailed to LPA Lee by POC Date 03/21/23 by 5 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-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
12/09/2022 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20221209110211

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: 9DATE:
03/21/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Edna CleggTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident is hospitalized for hypothermic and possible sepsis.
Due to staff neglect, resident sustained falls resulting in bruising.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Pang Lee and (LPA) Avelina Martinez made an unannounced visit to Clegg Care Facility on 03/21/2023 at 9:45 AM, to conclude the investigation of the above allegation and to deliver the findings. LPAs met with Administrator Edna Clegg and together discussed the investigation details.

Throughout the course of this investigation, the Department conducted interviews, reviewed facility files, and reviewed medical documents. Based on the investigation findings, it was learned there was no physical evidence to prove R1 bruises were a direct result of their the sustained falls. In addition, there was not sufficient evidence to prove due to facility neglect R1 became hypothermic and septic.

As a result, although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Physical Abuse are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

An exit interview was conducted, and a copy of this report was provided to the facility at the end of this visit.

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: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2023
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 4