342700317-5-16-2023-59-AS-LMUZ-CRXSKS-20230518135713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700317
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:13:43 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
05/11/2023 and conducted by Evaluator Talwinder Bains

COMPLAINT CONTROL NUMBER: 59-AS-20230511103820

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:	05/16/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Nelson Jacinto		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff pushed resident resulting in injury.
Staff disposed of resident's personal belongings.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 05/16/23 to do the complaint investigation for above allegations. LPA met with administrator Nelson Jacinto and explained the purpose of the visit. LPA wore the following Personal Protective Equipment (PPE) during today's visit-surgical mask. LPA was screened by facility staff upon entry.

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

**Report continued on LIC9099-C**

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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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-20230511103820

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: GRACE HOME II	FACILITY NUMBER: 342700317
	VISIT DATE: 05/16/2023

NARRATIVE

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***CONTINUED FROM LIC9099........***

Allegation-- Staff pushed resident resulting in injury.

On 05/16/23, Department conducted interviews with 3 staff and 3 residents to investigate this allegation. Interviews indicated that facility staff did not pushed R1 resulting in injury in any manner. Facility staff were treating all residents with dignity and respect and residents were happy with their care. During department visit on 05/16/23, staff were attentive to residents care needs and residents appeared to be happy and in good care at facility. Based on this information, this allegation is UNFOUNDED.

Allegation--Staff disposed of resident's personal belongings.

On 05/16/23, Department conducted interviews with 3 staff and 3 residents to investigate this allegation. Interviews indicated that facility staff were respectful towards residents personal belongings, art work and other personal items. Facility staff were not throwing or disposing any residents personal items without residents permission and helping residents to organize their personal items in their rooms. All residents including R1 indicated that there were no issues at the facility regarding this allegation. During department visit on 05/16/23, it has been observed that residents have their personal items/ belongings secured in their rooms with no issues. Based on this information, this allegation is 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.

No citations were issued today. Administrator gave permission to staff, Maria Segarra (Kory) to sign this report since administrator was not available for Exit meeting with LPA. Exit meeting conducted with Kory.
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: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC9099 (FAS) - (06/04)

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