342700029-10-19-2022-27-AS-KHOS-CKKNLG-20221026103332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700029
Report Date: 10/19/2022
Date Signed: 10/19/2022 03:57:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/07/2022 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20220907124313

FACILITY NAME:	CALI CARE RETIREMENT HOME		FACILITY NUMBER:	342700029
ADMINISTRATOR:	MOJICA, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	3630 WEST WAY		TELEPHONE:	(916) 484-3027
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	6	CENSUS: 4	DATE:	10/19/2022
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Emmanuel Mojica		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Financial Abuse: Staff made unauthorized transactions on resident's credit card

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Cali Care Retirement Home (RCFE) on 10/19/22 at 3:40pm to deliver findings regarding the allegation above. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because LPA was unable to locate and interview the alleged victim regarding the allegation. The alleged victim is a former resident of the facility who lived at the facility for a short time in 2019. LPA attempted to call and texted the alleged victim with no response. The only address the reporting party had for the former resident was a PO box address. LPA was unable to locate the alleged victim to gather more information regarding the allegations. All staff interviewed denied the allegations.

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

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-20220907124313

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: CALI CARE RETIREMENT HOME	FACILITY NUMBER: 342700029
	VISIT DATE: 10/19/2022

NARRATIVE

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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 Financial Abuse are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022

LIC9099 (FAS) - (06/04)

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