342700317-8-13-2024-59-AS-KHOS-D8AM6A-20240819091937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700317
Report Date: 08/13/2024
Date Signed: 08/13/2024 09:50:58 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/13/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240613135559

FACILITY NAME:	GRACE HOME II		FACILITY NUMBER:	342700317
ADMINISTRATOR:	NELSON JACINTO		FACILITY TYPE:	740
ADDRESS:	9260 LOMA LANE		TELEPHONE:	(916) 607-6225
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	24	CENSUS: 22	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator, Nelson Jacinto		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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9

Staff does not ensure bathrooms are kept in good repair.
Staff does not ensure residents dietary needs are being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 08/13/24 to deliver the complaint findings for above allegations. LPA met with administrator Nelson Jacinto and explained the purpose of the visit.

The department conducted records review ,facility observations ,staff and residents interviews to investigate the complaint.

**Report continued on LIC9099-C**

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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 6

Control Number 59-AS-20240613135559

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACE HOME II	FACILITY NUMBER: 342700317
	VISIT DATE: 08/13/2024

NARRATIVE

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***Report continued from 9099....

Allegation- Staff does not ensure bathrooms are kept in good repair.-Substantiated

The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. During facility visits on 06/20/24 and 07/09/24, Department observed that residents bathroom in Room #9 was not operable and repairs were needed. The shower had a leak and was inoperable. The toilet was leaking and did not flush properly. The ceiling and wall of the bathroom has what appears to be water damage. 2nd building resident's bathroom's mirror was found to be broken and not safe for resident's use. Residents who resided in Room # 9 indicated that facility was aware about their bathroom issues not failed to address the issue until the Department was involved. Based on gathered information, this allegation was found to be Substantiated.

Allegation -Staff does not ensure residents dietary needs are being met. Substantiated

The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. During Department visit to facility on 06/20/24, LPA Bains found multiple food items with expired dates in kitchen area. Resident (R1) was interviewed and indicated that facility was not following their dietary preference request and not serving the food which was of good quality. Based on gathered information, this allegation was found to be Substantiated.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is observed but not being cited today as it has been cited on 07/09/24 during case management visit.

Exit interview was conducted and copy of the report left at the facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/13/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240613135559

FACILITY NAME:	GRACE HOME II		FACILITY NUMBER:	342700317
ADMINISTRATOR:	NELSON JACINTO		FACILITY TYPE:	740
ADDRESS:	9260 LOMA LANE		TELEPHONE:	(916) 607-6225
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	24	CENSUS: 22	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator, Nelson Jacinto		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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9

Staff does not speak to residents in an appropriate manner.
Staff do not ensure residents are accorded personal privacy.
Staff did not ensure residents personal belongings were secured.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 59-AS-20240613135559

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACE HOME II	FACILITY NUMBER: 342700317
	VISIT DATE: 08/13/2024

NARRATIVE

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Report continued from 9099-A......
Allegation- Staff does not speak to residents in an appropriate manner. Staff do not ensure residents are accorded personal privacy.-Unsubstantiated.

The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. Based on the interviews conducted with the administrator, residents and staff members, it has been determined that there is no evidence of staff being inappropriate or disrespectful towards the residents. The administrator mentioned that staff may speak loudly to residents who are hard of hearing in order to effectively communicate with them. However, this does not indicate any misconduct or disrespect. The residents' interviews revealed that the staff provide care and assistance in a professional manner, and they denied experiencing any disrespect or misconduct from any staff member at the facility. Residents’ interviews indicated that staff were providing privacy while providing care to them. During the department's visits to the facility as part of the complaint investigation on 06/20/24, it was observed that the facility staff were attentive to the residents' care needs. The residents indicated that the staff were providing satisfactory care. Based on these findings, there is no substantiated evidence of staff being disrespectful or engaging in any misconduct towards the residents therefore, this allegation is UNSUBSTANTIATED.

Allegation- Staff did not ensure residents personal belongings were secured. Unsubstantiated.

The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. From the record review, it has been revealed that facility has record of all personal belongings for R1 in resident’s facility file per Title 22 regulations. Staff and residents interviewed indicated that facility was trying their best to safeguard all residents belongings but some residents have behavior to hide their belongings in other resident’s closets or in other areas in facility. Resident’s interviews did not indicate any concerns about their personal belongings not secured at the facility. Furthermore, during department visit on 06/20/24, it has been observed that R1 has their personal belongings in their closet and by their bedside as listed in R1’s personal belongings form. Based on all this information, this allegation is found to be Unsubstantiated.

A finding that the complaint allegations is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Exit meeting conducted and a copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH 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
06/13/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240613135559

FACILITY NAME:	GRACE HOME II		FACILITY NUMBER:	342700317
ADMINISTRATOR:	NELSON JACINTO		FACILITY TYPE:	740
ADDRESS:	9260 LOMA LANE		TELEPHONE:	(916) 607-6225
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY:	24	CENSUS: 22	DATE:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator, Nelson Jacinto		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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9

Staff does not ensure facility is kept free from pests.
Staff does not ensure residents are provided with clean linens.

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 59-AS-20240613135559

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: GRACE HOME II	FACILITY NUMBER: 342700317
	VISIT DATE: 08/13/2024

NARRATIVE

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***Report continued from 9099-A.....

Allegation- Staff does not ensure facility is kept free from pests.-Unfounded

The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. LPA obtained documents relevant to the allegation as well as interviewed staff regarding the allegation. It was stated that the Pest Control company just visited the facility a prior to the department’s visit on 06/20/2024. Pest Control sprayed the exterior and interior of the building including residents rooms. During facility tour of the facility on 06/20/24, LPA Bains did not observe any pests at the facility. The facility provided documentation of continued frequent visits from a pest control agency. Residents interviews indicated that they were not aware about any pests issues at the facility. Based on this information, this allegation is found to be Unfounded.

Allegation- Staff does not ensure residents are provided with clean linens. Unfounded

The Department conducted record review, facility’s observations, three (3) staff and four (4) residents interviews to investigate complaint allegation. During Department visit on 06/20/24, LPA Bains observed that facility has adequate linen supplies for all residents. Staff interviews indicated that there was no linen shortage at the facility and things were fine with linen supplies and usage. Residents interviews did not indicate any concerns in this area and expressed their satisfaction with clean linen supplies. Based on this information, this allegation was found to be Unfounded.

Based on the investigation,the preponderance of evidence standards has not been met. Therefore, the above all allegations is found to be UNFOUNDED. A finding that the allegations are unfounded means that the allegations are false, could not have happened, and/or is without a reasonable basis.

Exit meeting conducted and a copy of this report has been provided to facility.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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