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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700045
Report Date: 08/03/2023
Date Signed: 08/03/2023 10:43:55 AM

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
03/20/2023 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20230320163307
FACILITY NAME:ENCAREFACILITY NUMBER:
342700045
ADMINISTRATOR:WASDYKE, GINAFACILITY TYPE:
735
ADDRESS:11041 CARMENET WAYTELEPHONE:
(916) 594-9332
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:4CENSUS: 4DATE:
08/03/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maureen TorresTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Other: Client sustained concerning injury while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Encare ARF on 8/3/23 at 9:40am to conclude the investigation of the above allegations and to deliver the findings. 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. LPA attempted to interview alleged victim but alleged victim is non-verbal. LPA interviewed staff who did not witness the fall in the home but all stated it appeared resident fell wile transferring from couch which resulted in injury. LPA subpoenaed medical records from UC Davis and could not determine, based on the evidence provided, there was any information that would confirm the injury happened in another way that contradicted statements obtained from staff members regarding the injury sustained to resident. LPA conducted interviews with staff whose statements were consistent and the reporting party could not provide any evidence supporting the allegation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
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-20230320163307
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: ENCARE
FACILITY NUMBER: 342700045
VISIT DATE: 08/03/2023
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 Other 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2