342700585-4-28-2021-27-AS-SDOB-C2NQQA-20210503122203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700585
Report Date: 04/23/2021
Date Signed: 04/28/2021 10:50:16 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
06/25/2020 and conducted by Evaluator Arlene D Garcia

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200625160751

FACILITY NAME:	INDOCARE HOUSE 2		FACILITY NUMBER:	342700585
ADMINISTRATOR:	LOMENDEHE, PAUL		FACILITY TYPE:	740
ADDRESS:	8604 BANFF VISTA DR		TELEPHONE:	(916) 686-1253
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 5	DATE:	04/23/2021
		UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:	Paul Lomendehe		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

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Staff are not properly cleaning the facility.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arlene Garcia, conducted an unannounced complaint visit on this day for the purpose of concluding a complaint investigation. Due to COVID-19 and precautionary measures, the visit was conducted via telephone. On this day LPA met with Administrator (AD) Paul Lomendehe and explained the reason for the visit.

The initial 10-day visit was conducted on 7/2/2021. Through the course of the investigation, LPA conducted interviews and reviewed training records for staff.
It was alleged that the staff were not properly cleaning the facility after a resident dropped fecal matter on the carpet. LPA reviewed training records. All staff have documented training for cleaning up such spills/incidents. Staff interviewed were able to recite to LPA procedures per their training and reported following such procedures when the incident occurred. Witnesses interviewed, reported staff did not follow procedures. Based on information provided through interviews and documentation, it was unclear if staff did clean the facility as they were trained, therefore the allegation was deemed UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.

No deficiencies cited. An exit interview was conducted with Administrator Paul Lomendehe via telephone and a copy of this report was provided via email. An electronic email read receipt confirms receipt of these documents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

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-20200625160751

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: INDOCARE HOUSE 2	FACILITY NUMBER: 342700585
	VISIT DATE: 04/23/2021

NARRATIVE

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This agency has investigated the allegations noted above and have found that the complaint was UNSUBSTANTIATED, meaning that there was not a preponderance of evidence to prove or disprove that the allegation occurred as reported.

Exit interview was conducted with Administrator. Copy of the report sent to Administrator via e-mail. Administrator is to print out each report, sign it, and send back via email to LPA.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arlene D Garcia	TELEPHONE: 916-862-5907
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2021

LIC9099 (FAS) - (06/04)

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