340317817-2-12-2025-27-AS-PLEE-DDTMSZ-20250212085246

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 340317817
Report Date: 02/12/2025
Date Signed: 02/12/2025 08:52:51 AM

Document Has Been Signed on 02/12/2025 08:52 AM - 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 FACILITY		FACILITY NUMBER:	340317817
ADMINISTRATOR/ DIRECTOR:	CLEGG, EDNA S		FACILITY TYPE:	740
ADDRESS:	7249 CARMI STREET		TELEPHONE:	(916) 429-6444
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY: 10		CENSUS: 5	DATE:	02/12/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:24 AM
MET WITH:	House Manager, Maxwell Llorente.		TIME VISIT/ INSPECTION COMPLETED:	09:05 AM

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	Licensing Program Analyst, Pang Lee arrived on 02/12/25 for an unannounced inspection to follow up on a substantiated allegation complaint investigation. LPA Lee met with Caregiver/House Manager, Maxwell Llorente who informed LPA Lee that administrator Edna Clegg is on vacation and will return the end of the month. On March 21, 2023, the Department concluded a complaint investigation which alleged the following: Resident sustained a shoulder dislocation while in care. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1) Basic Services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health safety Code section § 1569.49. Facility staff failed to provide adequate care, supervision, and did not follow facility protocol, which is to leave any fallen residents on the floor until medical professionals arrive. Facility staff picked up a resident which resulted in the resident sustaining a bilateral shoulder dislocation. At the time of the complaint visit on March 21, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” Continued LIC 809-C

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CLEGG CARE FACILITY	FACILITY NUMBER: 340317817
	VISIT DATE: 02/12/2025

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This is evidenced by the facility failing to provide care and supervision in a timely manner due to staff not trained to properly lift residents that resulted in a resident (R1) being diagnosed with a bilateral dislocated shoulder and a pelvis fracture, which is serious bodily injury.

Today, 02/12/25 the Department will be issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on March 21, 2023, the amount of the civil penalty issued today will be $9,500.

Exit interview conducted. A copy of the report has been issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of the LIC 421D.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

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