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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700092
Report Date: 11/21/2024
Date Signed: 11/21/2024 10:03:03 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2024 and conducted by Evaluator Christina Valerio
COMPLAINT CONTROL NUMBER: 27-AS-20240816113444
FACILITY NAME:WELLCARE HOMES 1FACILITY NUMBER:
342700092
ADMINISTRATOR:BERNADAS, ANTONIOFACILITY TYPE:
735
ADDRESS:10082 COSBY WAYTELEPHONE:
(916) 647-4573
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:5CENSUS: 4DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:MA THERESA MATATIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Staff physically abused client
Staff restrained resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to deliver complaint investigation findings. LPA Valerio met with Administrator Ma Theresa Mata, and explained the purpose of the visit.

The investigation consisted of the review of facility records, staff interviews, and resident interviews. The following has been determined as it relates to the aforementioned allegations.

A report was sent to the Regional Office alleging that Resident 1 (R1) was tied up by a staff member at Wellcare Homes 1. In another incident, it was reported that R1 was observed to have a black eye during Day Program.

According to facility records, on 08/14/2024, R1 arrived home from day program. After a few minutes, staff observed a dark colored discoloration under the lower portion of his left eye.
Continues on LIC 9099 - C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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-20240816113444
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WELLCARE HOMES 1
FACILITY NUMBER: 342700092
VISIT DATE: 11/21/2024
NARRATIVE
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Continues from LIC 9099

Staff then immediately notified administrator Ma Theresa Mata. The administrator contacted the manager at the day program, which stated they did not notice any discoloration while R1 was at Day Program.

According to an interview with Staff 1 (S1), S1 reported that the transportation company reported that they did not observe anything unusual with R1 that day.

According to an interview with Staff 3 (S3) and Staff 4 (S4), they did not observe any physical abuse towards R1 nor have they ever used restraints on any of the residents.

LPA Valerio attempted to interview residents in care; however, due to communication barriers, the interviews were deemed unsuccessful.

Due to the above noted information, although the allegation(s) may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, no deficiencies are being cited. An exit interview was held and a copy of report was left at the facility with Administrator Ma Theresa Mata.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2