342700369-3-12-2021-27-AS-KHOS-BZEQEN-20210324120636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700369
Report Date: 03/11/2021
Date Signed: 03/12/2021 01:17:22 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
03/05/2021 and conducted by Evaluator Tirzah Hubbard

COMPLAINT CONTROL NUMBER: 27-AS-20210305112013

FACILITY NAME:	COMMONS AT ELK GROVE, THE		FACILITY NUMBER:	342700369
ADMINISTRATOR:	COURTNEY HILL		FACILITY TYPE:	740
ADDRESS:	9564 SABRINA LANE		TELEPHONE:	(916) 683-6833
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	110	CENSUS: 89	DATE:	03/11/2021
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Courtney Hill		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Food containing foreign material served to resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (s) (LPA) Tirzah Hubbard & Victoria Brown contacted the facility via telephone to commence an unannounced Tele-visit on 3/11/21 at 11:00am due to COVID-19 and pre-cautionary measures. LPA's conducted the visit using an iPhone feature. LPA's met with Courtney Hill the Executive Director and discussed the purpose of the call and the elements of this type of visit.
On 3/10/21, LPA's toured the facility physical plant to observe menus and the food preparation process. LPA's interviewed Executive Director and Director of Dining Services and Resident #1 (R1) during this visit. LPA's requested the following documents to be submitted via fax: Copy of the food menu for the week of March 1, 2021, (LIC602) Physicians Report for R1. A copy of all the kitchen staff work schedule for the week of March 1, 2021 along with their contact information.
During the tour on 3/10/21 LPA's observed the kitchen area, food items that were maintained in Styrofoam containers and food that were covered in saran wrap on trays inside of the refrigerator, along with utensils that are individually pre-wrapped from a company named Cisco.

Unfounded

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

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-20210305112013

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: 03/11/2021

NARRATIVE

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LPA's and Director of Dining Services observed in R1’s room the food items questioned. The team observed a Styrofoam container in the refrigerator. The Director of Dining Services stated what was found in the container.

The container included potatoes, raspberries, possible green beans, possible raisins, and the wrapper from the utensils. LPA's observed the items mentioned to be mixed together and the wrapper was observed in a separate area of the container.

The investigation revealed that through interviews and observation that saran wrap was not delivered with R1’s meal. In addition, LPA’s observation revealed that saran wrap was not observed to be lodged into the food.

The preponderance of evidence standards has not been met. Therefore, the allegation is deemed to be UNFOUNDED.

“This agency has investigated the complaint alleging, the above-mentioned allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed during this visit. An exit interview was conducted with Courtney Hill via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

LIC9099 (FAS) - (06/04)

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