342700587-9-9-2021-27-AS-KHOS-C6VJ6R-20210915064643

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700587
Report Date: 09/09/2021
Date Signed: 09/09/2021 04:10:53 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
06/24/2021 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20210624161723

FACILITY NAME:	SIGNATURE LIVING ON LAVELLI WAY		FACILITY NUMBER:	342700587
ADMINISTRATOR:	ENERO, EDGAR		FACILITY TYPE:	740
ADDRESS:	10125 LAVELLI WAY		TELEPHONE:	(916) 812-0944
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 5	DATE:	09/09/2021
		UNANNOUNCED	TIME BEGAN:	03:40 PM
MET WITH:	Caregiver, Belinda Alagbate		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained unexplained injury while in care.
Staff did not seek medical attention for resident in a timely manner.

INVESTIGATION FINDINGS:

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On 9/9/2021 at 3:40 PM, Licensing Program Analyst (LPA) Tung Truong conducted an unannounced visit to this facility to deliver the complaint findings. Upon LPAs arrival, Caregiver Belinda Alagbate was present at facility and contacted Administrator Edgar Enero. LPA Truong spoke with Administrator Edgar Enero on the phone to explain the purpose of the visit and informed the administrator of the complaint findings.

Throughout the course of the investigation, LPA conducted interviews and reviewed records. The investigation revealed that R1 was admitted to the hospital with right hand swelling and blisters. Staff (S1, S2, S3, and S4) didn’t notice anything unusual to R1 while in their care. Staff have no idea how R1 has sustained blisters on the right hand. R1 is non-verbal and could not speak to what happened. According to the Administrator and R1's family, R1 has a habit of putting a finger in R1's mouth.

Report continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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-20210624161723

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: SIGNATURE LIVING ON LAVELLI WAY	FACILITY NUMBER: 342700587
	VISIT DATE: 09/09/2021

NARRATIVE

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The complaint also alleged that staff did not seek medical attention for resident in a timely manner.

Based on interviews conducted and reviewed records, there was insufficient evidence to substantiate that staff did not seek medical attention for resident (R1) in a timely manner. Staff (S3) and (S4) stated that they did not observed anything unusual happened to R1 and to R1’s hand on Sunday. Staff (S1) and (S2) stated that they noticed the blisters on R1’s hand on Monday morning and immediately alerted the Administrator. Paramedic was called immediately and R1 was taken to the hospital for evaluation.

Based on LPAs observations, interview and record review, the department finds the allegations above to be UNSUBSTANTIATED- A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview was conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC9099 (FAS) - (06/04)

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