340317817-7-18-2023-27-AS-KHOS-CV6H7Z-20230829055734

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

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

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
07/10/2023 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230710165633

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: 7	DATE:	07/18/2023
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Edna Clegg		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility failed to maintain hot water for residents.

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 Lee met with 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. At 9:40 AM, LPA Lee toured the facility and two facility bathrooms. LPA Lee also checked the facility water temperature in both bathrooms. Facility bathroom #1 sink and shower water was measured at 112.3 degrees Fahrenheit and facility bathroom #2 sink and shower was measured at 150.3 degress Fahrenheit. Licensee did not maintain bathroom #2 resident sink and shower water temperature to be within regulatory range of 105 to 120 degrees Fahrenheit. LPA Lee advised licensee to place a visable warning sign stating that the water temperature is hot at both the resident sink and shower. Licensee agrees and posted a visable warning signs in bathroom #2 sink and shower.
Continued LIC 9099 C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (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)

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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/19/2023 Section Cited CCR 87303(e)(3)	1 2 3 4 5 6 7	87303 Maintenance and Operation Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degree C) or above shall be prominently identified by warning signs. This requirement is not met by evidence by:	1 2 3 4 5 6 7	The Licensee agrees to post a warning sign to notify of hot water temperature at bathroom #2 sink and shower. LPA Lee observed Licensee posted the hot water warning sign in resident bathroom #2 sink and shower. Licensee agrees to get water temperature down to 105-120 within the regulation requirement. Licensee agrees to take a video of the water temperature being measure and send the
	8 9 10 11 12 13 14	Based on observation and interview the licensee did not maintain bathroom #2 sink and shower water temperature to be within regulatory range. Bathroom #2 sink and shower hot water measured at 150.3 *F without a prominently placed warning sign present which poses an immediate risk to staff and residents in care.	8 9 10 11 12 13 14	video to LPA Lee by POC 07/19/2023 by 5:00 PM end of day.
	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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023

LIC9099 (FAS) - (06/04)

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

An exit interview was conducted with licensee, Edna Clegg, and a copy of the 9099 report, 9099A, 9099-D page, and appeals right document were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (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)

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