342700369-11-5-2021-27-AS-KHOS-C9AKSK-20211201070939

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700369
Report Date: 11/05/2021
Date Signed: 11/05/2021 01:02:34 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
09/17/2021 and conducted by Evaluator Tirzah Hubbard

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210917151434

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: 80	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Executive Director Meggin Cortez		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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9

Resident has unexpected weight loss.

INVESTIGATION FINDINGS:

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13

On 11/05/2021 at 11:20am Licensing Program Analyst (LPA) Tirzah Hubbard conducted an onsite inspection to deliver the investigation findings of the following allegations: "Resident has unexpected weightloss". LPA met with Executive Director Meggin Cortez and stated the purpose of the visit.

During the Investigation LPA TIrzah Hubbard reviewed Resident Three's (R3)’s Physicians orders for diet changes due to aspiration causes. Based on Interviews and records review physicians records and orders, R3's weight loss was caused due to Physicians order requirements,diet changing to a liquid diet. Staff 1 documented the diet change and informed the responsible party to R3.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.No deficiencies were cited on todays visit. An exit interview was held and a signature on this report acknowledges a copy was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

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
09/17/2021 and conducted by Evaluator Tirzah Hubbard

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20210917151434

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: 80	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Executive Director Meggin Cortez		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee yells at Resident and family.

Licensee is unlawfully threating to raise rent.

INVESTIGATION FINDINGS:

1
2
3
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5
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13

On 11-5-2021 LPA Hubbard conducted a complaint visit to deliver findings for allegations,
"Licensee yells at resident and family" & " Licensee is unlawfully threatening to raise rent".
The purpose of this visit was to complete this complaint investigation and deliver the findings to this facility.
Based on interviews with staff and residents, it was revealed that this facility does not yell at residents or families. The facility maintains a professional and safe environment at all times.
Based on records review and documentation, it was learned the facility maintained lease agreement guidelines for persons in care sending updates through email for raising rent cost and additonal fees.
Based on an interview with Executive Director it was learned the faciltity did adhere to the agreement and fees,raising the rent was lawful.
In addition, interviews conducted with staff concluded that the facility contacts each responsible party through mail and email when raising rent fees

The preponderance of evidence standards has not been met. Therefore, the allegation was deemed to be UNFOUNDED for both allegations.

Unfounded

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 2