342700489-9-7-2023-59-AS-MSEY-CVGRYA-20230908132600

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700489
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:03:41 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2023 and conducted by Evaluator Angela Hood

COMPLAINT CONTROL NUMBER: 59-AS-20230901083711

FACILITY NAME:	PALMS COURT I		FACILITY NUMBER:	342700489
ADMINISTRATOR:	OGUNDWIN, ADEOLA		FACILITY TYPE:	740
ADDRESS:	6821 LINCOLN AVE		TELEPHONE:	(916) 993-8166
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 1	DATE:	09/07/2023
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Charles Ankrah, Caregiver		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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-Staff negligence resulted in resident sustaining (2) stage IV pressure injuries.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angela Hood arrived at the care home and met with Caregiver, Charles Ankrah, to close the complaint into the allegation listed above.

This complaint was filed under the wrong facility.

Due to complaint not applying to this facility, the above allegation is found to be UNFOUNDED. A finding that the allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiencies are being cited. Exit interview conducted. A copy of the report provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (916) 214-0485
LICENSING EVALUATOR NAME: Angela Hood	TELEPHONE: 650-676-0390
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023

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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