342700317-9-10-2024-59-AS-KHOS-D92J6U-20240912064654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700317
Report Date: 09/10/2024
Date Signed: 09/10/2024 10:26:05 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
09/06/2024 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20240906162443

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: 20	DATE:	09/10/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Nelson Jacinto		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Client wandered away from the facility due to lack of care or supervision from staff .

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 09/10/24 to do the complaint investiagtion for above allegation. LPA met with administrator Nelson Jacinto and explained the purpose of the visit. LTCO, Byron Toliver was also present during this visit.

From record review, administartor and resident (R1) interviews, it has been concluded that R1 AWOL from facility on 09/05/24 sometime after 11AM and was located at El Hogar Clinic, 630,Bercut Drive, Suite # C, Sacramento,CA,95811 (19 miles away from facility) and El Hogar staff notified facility regarding R1s presence at the clinic around 1PM. It was indicated that R1 was very thirsty and clammy when Clinic staff found R1. R1 was transferred to local hospital to get medical care and discharge to facility on 09/05/24 around 10PM. R1s LIC602 ,dated- 01/17/24 signed by thier physician disclosed that R1 cannot leave facility unassisted. From all gathered information, it has been conlcuded that R1 had AWOL from facility unassisted and unsupervised on 09/05/24 due to lack and care from facility. Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards has been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, a deficiency is cited.Exit interview was conducted .Copy of the report and appeal rights were left provided. Civil penalties shall be assessed if facility does not comply with POC requirements which were issued today.

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: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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 59-AS-20240906162443

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/11/2024 Section Cited CCR 80078(a)	1 2 3 4 5 6 7	80078(a) Responsibility for providing care and supervision. The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility agrees to hold a training on the AWOL procedure with all staff and send a copy of topics covered and a list of attendees name/date/signature by POC date, 09/11/24 and provide staffing as necessary to meet residents needs.
	8 9 10 11 12 13 14	Based off of observation and record reviews ,it has been concluded that resident, R1 AWOL'd from the facility on 09/05/24 due to lack of care and supervision of staff which presents an immediate health and safety risk to the resident in care.	8 9 10 11 12 13 14	Facility agrees to revisit AWOL procedure and to submit in a written AWOL procedure to CCL within 15 days.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder Bains	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC9099 (FAS) - (06/04)

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