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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700716
Report Date: 12/17/2021
Date Signed: 03/24/2022 03:12:15 PM

Unsubstantiated


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
10/01/2021 and conducted by Evaluator Tirzah Hubbard
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20211001100430
FACILITY NAME:MIRANDA GARDENSFACILITY NUMBER:
342700716
ADMINISTRATOR:MIRANDA, IANFACILITY TYPE:
735
ADDRESS:2405 RENWICK AVETELEPHONE:
(916) 955-1905
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY:4CENSUS: 4DATE:
12/17/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Pamela Miranda TIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff handled resident in a rough manner.

Staff speaks to resident in an inappropriate manner.

Staff yelled at resident.

Staff isolated resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Original documents were amended due to these being generated in error. The findings can be found on the LIC 9099 and LIC 9099-A dated 03/24/2022.

Licensing Program Analysts (LPA)s Tirzah Hubbard conducted an unannounced complaint visit on 12-17-21 and was met by Licensee Pamela Miranda to discuss the findings of the complaint. Current census of the facility was 4
The purpose of this visit was to complete this complaint investigation and deliver the findings to this facility. Based on interviews and information gathered during the course of this investigation, it was revealed that the facility staff did not handle R1 in a rough manner. Third party personnel identified and observed that staff in the facility did not touch or physically handle the residents in any manner. There have not been any reports submitted into this third party vendor alleging the violation of residents' rights by the facility staff for roughly handling residents. Based on an interview with third party personnel, it was learned that S1 did not speak to the resident in an inappropriate manner. The third party personnel did not receive reports or documentation of the allegation between S1 yelling at R1. On 10-1-21 LPA Hubbard and the third party vendor toured the physical plant of this facility. It was observed that R1's room contained a lock on the door and a additional exit point in the room through another door. R1 was able to unlock the door from the inside and leave when needed to. Based on a review and observation of the door lock from the resident's room, it did not appear that staff isolated R1.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
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
Control Number 27-AS-20211001100430
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: MIRANDA GARDENS
FACILITY NUMBER: 342700716
VISIT DATE: 12/17/2021
NARRATIVE
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27
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32
 Based on all the information collected by the Department there is not a preponderance of evidence to prove the allegation occurred, therefore this allegation is UNSUBSTANTIATED.  Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, and therefore the allegations are unsubstantiated. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview was held and  a copy of report was left at the facility.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2