342700369-11-2-2023-27-AS-KHOS-CXBMW3-20231106085739

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700369
Report Date: 11/02/2023
Date Signed: 11/02/2023 09:32:46 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
09/27/2023 and conducted by Evaluator Vincent Moleski

COMPLAINT CONTROL NUMBER: 27-AS-20230927093125

FACILITY NAME:	COMMONS AT ELK GROVE, THE		FACILITY NUMBER:	342700369
ADMINISTRATOR:	MEGGIN CORTEZ		FACILITY TYPE:	740
ADDRESS:	9564 SABRINA LANE		TELEPHONE:	(916) 683-6833
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	110	CENSUS: 90	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Meggin Cortez		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care
Facility staff are not preventing resident from physically assualting another resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Meggin Cortez and explained the purpose of the visit.

This investigation consisted of interviews, record review and observation.

LPA Moleski reviewed three months’ worth of incident reports received via fax from this facility. LPA Moleski did not observe any incident reports describing physical altercations between residents as alleged in this complaint.

LPA Moleski interviewed eight residents (R2, R11-R17) and 11 staff members (S1-S11). None of the residents or staff members interviewed were aware of any physical altercations that had occurred between residents as alleged in this complaint. [continued on 9099-C]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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 27-AS-20230927093125

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: COMMONS AT ELK GROVE, THE	FACILITY NUMBER: 342700369
	VISIT DATE: 11/02/2023

NARRATIVE

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None of the staff members interviewed had observed any unusual or unexplained bruising on residents during body checks of residents.

LPA Moleski did not observe any unusual bruising on any residents seen while in the facility.

The department has determined the following as it relates to the allegations that a resident sustained unexplained bruising while in care and that facility staff are not preventing a resident from physically assaulting another resident in care:

Based on observation, record review, and interviews, the above allegations are UNSUBSTANTIATED, which means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies were cited during this visit. An exit interview was conducted and a copy of this report was left with Cortez.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Vincent Moleski	TELEPHONE: (559) 365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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