342700369-3-4-2021-27-AS-LKIG-BYX4JD-20210308180833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700369
Report Date: 03/04/2021
Date Signed: 03/04/2021 06:11:12 PM

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
06/01/2020 and conducted by Evaluator Ashley Boothe

COMPLAINT CONTROL NUMBER: 27-AS-20200601150001

FACILITY NAME:	COMMONS AT ELK GROVE, THE		FACILITY NUMBER:	342700369
ADMINISTRATOR:	TALANI, MICHAEL		FACILITY TYPE:	740
ADDRESS:	9564 SABRINA LANE		TELEPHONE:	(949) 242-1400
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	110	CENSUS: 89	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Courtney Hill		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Staff did not safeguard resident's property.

INVESTIGATION FINDINGS:

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On 3/2/2021 at 9:34am Licensing Program Analyst (LPA) Ashley Boothe contacted Administrator Courtney Hill and stated the purpose of the visit to deliver the findings of a complaint investigation with the allegation: Staff did not safeguard resident's property. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19. Current Census 89

During the investigation, LPA reviewed Resident one (R1)’s admissions agreement, personal property and valuables, community handbook signed by R1, and community’s theft and loss policy. R1's signed admission’s agreement states the facility “shall not be responsible for the loss of any personal property belonging to you due to theft, fire, or any other cause, unless the loss or damage was caused by our negligence or that of our employee. We strongly recommend that you obtain, at your own expense insurance for the replacement value of your personal property, at adequate cover and liability limits".

Continued on 9099 C. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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 27-AS-20200601150001

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: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
	VISIT DATE: 03/04/2021

NARRATIVE

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Continued from 9099. Page 2 of 2.

LPA conducted interviews with R1, R1’s daughter, Staff one (S1), Staff two (S2), and Administrator. During the interviews it was stated the missing item was a decorative bird placed outside the R1’s room at the end of a common hallway. The bird was clipped with an alligator clip to an artificial flower in a decorative basket. R1 likes to decorate the area and has permission to put up decorations, but has been advised by Administrator to not put “special items out there”. R1 stated she takes responsibility for the items she places outside of her room. R1 stated she reported it missing, multiple staff assisted in looking for the bird in resident’s rooms and staff assisted in posting signs in the community. S1 and S2 stated they were trained on the community’s polices and assisted R1 is looking for the item. R1’s daughter stated, “someone took it, a resident or employee is unknown”. While the item was found to go missing, during record review and interview LPA did not find negligence on the facility's part in not safeguarding the R1’s property as R1 placed the item outside their room in a common hallway. R1 did not fill out a personal property log upon move in and R1's daughter stated it was not offered to them during initial signing of documents.

Based on information obtained the aforementioned allegation is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

There are no deficiencies being cited per Title 22 Regulations. Exit interview was conducted with Courtney. Copy of the report was sent to via e-mail with a "read receipt" to verify the LIC 9099, 9099 C, and Appeal Rights were received. Courtney is to print out the report and fax signed copies to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

LIC9099 (FAS) - (06/04)

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