342700029-3-3-2023-27-AS-KHOS-CPPSGM-20230307125209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700029
Report Date: 03/03/2023
Date Signed: 03/03/2023 02:01:15 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
01/12/2023 and conducted by Evaluator Avelina Martinez

COMPLAINT CONTROL NUMBER: 27-AS-20230112115006

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: 5	DATE:	03/03/2023
		UNANNOUNCED	TIME BEGAN:	09:59 AM
MET WITH:	Theresa Mata		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not meeting resident’s hygiene need.
Staff does not ensure resident has clean linens.
Staff are not following physician's orders.
Staff are not providing incontinent care to resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 03/03/2023 at 11:19 AM, Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced to deliver complaint findings. LPA met with Theresa during today’s visit and explained the purpose of today's visit.

Throughout the course of this investigation, LPA Martinez conducted interviews and reviewed facility records. Based on four out five resident interviews, LPA Martinez was informed the facility is sanitary and clean. In addition, the four out of five residents did not have any complaints about care and supervision, and they are satisfied with the care they are receiving. In addition, during facility visits, LPA Martinez observed the facility to be clean and residents' linens were cleaned. Futhermore, LPA Martinez did not smell any foul odors at the facility during visits.

Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

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 2

Control Number 27-AS-20230112115006

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: 03/03/2023

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
26
27
28
29
30
31
32

Moreover, it was learned resident 1 (R1) is no longer residing at this facility and whereabouts are unknown. LPA Martinez was informed R1 was transferred to a facility that could provide R1 a higher level of care. However, LPA Martinez reviewed R1's facility file. Based on facility records review, it was learned R1 had a history of refusing hygiene care, incontinent care, and transferring care. Facility records indicated R1 was encouraged to accept care and at times R1 agreed to receive care. Additionally, witness 1 (W1) reported having no issues or concerns with the care R1 was receiving at the facility. W1 also reported that facility staff were informing them of any refusal of care. Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2