342700638-11-7-2024-59-AS-KHOS-DBLUZ5-20241203150057

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700638
Report Date: 11/07/2024
Date Signed: 11/07/2024 01:21:36 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
10/29/2024 and conducted by Evaluator Cassie Yang

COMPLAINT CONTROL NUMBER: 59-AS-20241029105016

FACILITY NAME:	ESTHER CARE HOME		FACILITY NUMBER:	342700638
ADMINISTRATOR:	EGUAVOEN, CHARLES		FACILITY TYPE:	740
ADDRESS:	4415 ROLLINGROCK WAY		TELEPHONE:	(916) 560-3800
CITY:	CARMICHAEL	STATE: CA	ZIP CODE:	95608
CAPACITY:	6	CENSUS: 3	DATE:	11/07/2024
		UNANNOUNCED	TIME BEGAN:	09:57 AM
MET WITH:	Charles Eguavoen		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility is physically abusing resident

INVESTIGATION FINDINGS:

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On November 7, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to investigate and deliver the findings of a complaint the department received. LPA met with Licensee and explained the purpose for visit.

During today's visit, LPA conducted file review and interviews.

Please see LIC 9099-C for the result of the investigation.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

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 59-AS-20241029105016

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ESTHER CARE HOME	FACILITY NUMBER: 342700638
	VISIT DATE: 11/07/2024

NARRATIVE

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LIC 9099-C

Allegation: Facility is physically abusing resident.

The Department conducted extensive interviews and file reviews. Based on interview conducted with Administrator, it revealed R1 was transported to the emergency room for low O2 levels who then was discharged to be on hospice services. R1 is no longer at the facility as R1's responsible party had wished for R1 to be at home during this stage of R1's life. Based on interview conducted with R2 revealed that R2 has never been physically abused at the facility by staff. Based on interview conducted with R3 revealed R3 wished to not be disturbed at this time. Based on interview conducted with R4 revealed that R4 has never seen residents being abused at the facility and/or R4 has never been abused at the facility.

File review conducted revealed that R1 "can be forgetful" but no indication of dementia. File review conducted for R2 revealed R2 has mild cognitive impairment. File review conducted for R3 revealed R3 has dementia. File review conducted for R4 revealed R4 has mild cognitive impairment. Based on the SOC 341 received and reviewed, it revealed resident has not and/or is not being abused.

Based on information obtained throughout this investigation, the allegation listed above is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Exit interview conducted and a copy of the report was left at the facility.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie Yang	TELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024

LIC9099 (FAS) - (06/04)

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