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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 340317817
Report Date: 08/18/2023
Date Signed: 08/18/2023 01:42:41 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
PUBLIC
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: 8DATE:
08/18/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Edna CleggTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility staff withheld mail from resident.
Staff yelled at resident.
INVESTIGATION FINDINGS:
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On 08/18/2023 at 1:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at this facility to conduct a complaint visit. LPA Lee met with Licensee/administrator, Edna Clegg and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above. Throughout the course of this investigation, the Department conducted interviews, reviewed facility files, and reviewed medical documents.

Allegation: Facility staff withheld mail from resident
It was alleged that the facility withheld mail from resident. LPA Lee conducted 7 out of 8 resident interviews. LPA Lee was not able to interview one resident. It was learned that 6 out of 7 residents had no concerns regarding facility staff withheld mail from residents. It was also learned that the mail man place mails in the locked mailbox. Licensee has the key to the mail and distributes residents’ mails as they are delivered to the facility.
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: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
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 5
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: 08/18/2023
NARRATIVE
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Allegation: Staff yelled at residents.
It was alleged that the facility staff yelled at residents. LPA Lee conducted 7 out of 8 resident interviews. LPA Lee was not able to interview one resident. It was learned that 6 out of 7 residents has no concerns with facility staff yelling at residents. During complaint investigation on 07/18/2023 and 08/07/2023 LPA Lee did not observe facility staff yelling at residents.

As a result of this investigation, and based on LPA’s observations, and interviews the allegation(s) are deemed to be UNSUBSTANTIATED - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiencies are being cited.
An exit interview was conducted, and a copy of this report 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: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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: DATE:
08/18/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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9
Staff confiscated resident's personal items.
Food is inaccessible to residents in care.
INVESTIGATION FINDINGS:
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On 08/18/2023 at XXXXX, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at this facility to conduct a complaint visit. LPA Lee met with administrator, Lita Vinluan and explained the purpose of the visit. The purpose of this visit was to deliver complaint findings for the allegations above.
Throughout the course of this investigation, the Department conducted interviews, reviewed facility files, and reviewed medical documents.

Allegation: Staff confiscated residents’ personal items.
It was alleged that the staff confiscated resident’s items. On 07/18/2023 complaint investigations visit, it was learned that licensee kept resident 1 (R1) snacks that (R1) order online in the pantry. The pantry is in the kitchen. It was also learned that resident is not allowed to go into the kitchen. On 08/07/2023 complaint investigation visit, LPA Lee questioned Licensee regarding (R1) Husky tool set and licensee brought the Husky tool set out of the kitchen and showed it to LPA Lee. It was also learned on 08/07/2023 that (R1) ordered the 75 piece Husky tool set from Home Depot.
Continued LIC 9099-C
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: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 08/18/2023
NARRATIVE
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 It was also learned that once the tool set arrived at the home, licensee confiscated (R1)’s Husky tool set on 05/10/203. On 08/07/2023, Licensee showed LPA Lee a signed document stating that resident can not keep sharp tools and that licensee kept the tool in a safe storage and when resident needs the tool resident can use it with staff supervision. LPA Lee opened the tool set and did not observed any sharp tools. It was also learned that resident and Telecare worker came to the facility on 07/21/2023, 08/01/2023 and 08/04/2023 to pick up (R1) personal items since (R1) moved out. It was learned on those three days (R1) tool set was not given to (R1) when (R1). LPA Lee asked licensee how she would ensure (R1) gets (R1) tool set and licensee stated that (R1) would need to pay what (R1) owe in rent first.

Allegation: Food is inaccessible to residents in care.

It was alleged that food is inaccessible to resident in care. LPA Lee conducted 7 out of 8 resident interviews. LPA Lee was not able to interview one resident during the complaint investigation. 5 out of 7 residents stated that residents are not allowed to go into the kitchen and that the kitchen door is locked. It was learned that if resident wanted food and snacks resident will go to the open kitchen window to ask for food and snacks. LPA Lee also conducted 3 out of 4 staff interviews and it was also learned that resident is not allowed in the kitchen and that residents can ask for snacks and food and then facility staff will give it to residents. Based on observations on 07/18/2023 and 08/07/2023 LPA Lee observed the kitchen door was not locked; however, it was learned on 07/18/2023 during the complaint visit, licensee stated that residents were not allowed in the kitchen due to licensee cooking and that it was not safe for residents if she had to step away while cooking. It was also learned on 07/19/2023 through an email form a facility staff that residents are not allowed in the kitchen because the facility have some refrigerated medication that is stored in the fridge and that there is also no partition to separate the kitchen from the room with all the cleaning supplies which making medications and cleaning supplies accessible to residents.

As a result of this investigation, the department find the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

An exit interview was conducted, a copy of the LIC 9099, LIC9099-C, LIC9099-D and appeals rights were provided to the facility at this 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: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 08/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
87468.1(a)(3)
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Personal Rights: ..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from...interfering with daily living functions such as eating, sleeping, or elimination.
This was not met as evidenced by:
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Liicensee agrees to review regulation cited and provide a statement to LPA Lee that the regulation has been read and understood by all facility staff. POC will be emailed to LPA Lee by POC date 08/25/2023 by 5:00 PM by end of day.
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Based on observation and interviews, licensee does not allow resident to go into the kitchen. The kitchen is locked, this posed a potiential health and safety risk to residents in care.

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Type B
08/25/2023
Section Cited
CCR
87468.1(a)(12)
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87468.1(a)(12) Personal Rights of Residents in all Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: or wear their own clothes; to keep and use their own personal possessions...This requirement was not met as evidence by:
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Liicensee agrees to review regulation cited and provide a statement to LPA Lee that the regulation has been read and understood by all facility staff. POC will be emailed to LPA Lee by POC date 08/25/2023 by 5:00 PM by end of day.
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Based on record review and interviews, the Licensee confiscated R1's snacks and Husky 75 pieace tool set, which posed a potential health and safety risk to residents in care.
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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: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5