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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700731
Report Date: 02/16/2021
Date Signed: 02/16/2021 09:20:13 AM



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
06/26/2020 and conducted by Evaluator Tuyet-Suong Teh
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200626130727
FACILITY NAME:LOVE AND COMFORT ELDERLY CAREFACILITY NUMBER:
342700731
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(916) 594-9378
CITY:SACRAMNETOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
02/16/2021
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Ratu VunimatanaTIME COMPLETED:
09:17 AM
ALLEGATION(S):
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Facility staff failed to meet the resident's needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Suong Teh contacted the facility via telephone to commence a complaint investigation via telephone on 02/16/2021 due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call and the elements of the allegation(s) with the facility administrator Ratu Vunimatana.
Allegation: Facility staff failed to meet the resident's needs.
On 07/03/2020 the Department conducted an initial 10 days complaint investigation and interviewed the reporting party (R1) and staff #1(S1).
On 09/03/2020, the Department interviewed witness #1 (W1). LPA learned from interviews that resident #1 (R1) go to dialysis three times a week. W1 stated on two occasions 07/16/2020, and 07/21/2020, when R1 was being picked up to the dialysis appointment, R1 walked to the bus without any shoes and her hair was observed to be uncombed. On another occasion 11/17/2020, W1 stated @0837 hours, W1 was at the facility and found the facility to have a strong urine smell. W1 stated that she found the staff in her room resting. The department obtained pictures of R1 on 07/16/2020 and 07/21/2020.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
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 5
Control Number 27-AS-20200626130727
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: LOVE AND COMFORT ELDERLY CARE
FACILITY NUMBER: 342700731
VISIT DATE: 02/16/2021
NARRATIVE
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The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of regulations, Title 22. Deficiencies are being cited on the attached LIC9099D. An exit interview was conducted with Ratu Vunimatana via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20200626130727
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: LOVE AND COMFORT ELDERLY CARE
FACILITY NUMBER: 342700731
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2021
Section Cited
CCR
87464(f)(2)
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Basic Services: Basic services shall at a minimum include: Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services.
This requirement is not met as evidenced by: Based on interviews and records review,
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Licensee agreed to conduct an in-service training regarding basic services and submit training materials along with a signed staff roster to LPA by POC date.
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On two occasions 07/16/2020, and 07/21/2020, when R1 was being picked up the dialysis appointment, R1 walked to the bus without any shoes and her hair was observed to be uncombed.
the licensee did not ensure safe and healthful living to residents in care. This posed an immediate health and safety risk to residents in care.
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Licensee and LPA agreed to the following plan of correction. LPA advised Facility through complaint investigation to hold, log and ensure facility staff are familiar with mental health diagnosis and have training to support those residents in care. Licensee will sumbit to LPA the POC by 02/17/21.
Type A
02/17/2021
Section Cited
CCR
87411(d)(3)
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Personnel Requirements: All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
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(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not ensure safe and healthful living to residents in care. This posed an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
06/26/2020 and conducted by Evaluator Tuyet-Suong Teh
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200626130727

FACILITY NAME:LOVE AND COMFORT ELDERLY CAREFACILITY NUMBER:
342700731
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(916) 594-9378
CITY:SACRAMNETOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: DATE:
02/16/2021
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Ratu VunimatanaTIME COMPLETED:
09:17 AM
ALLEGATION(S):
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Facility staff failed to observe resident's change in condition.
INVESTIGATION FINDINGS:
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Based on interviews and resident #1 (R1) current physician report, care plan and medication records reviewed. The preponderance of evidence standards has not been met; therefore, the above allegation(s) is found 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.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted with Ratu Vunimatana via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
06/26/2020 and conducted by Evaluator Tuyet-Suong Teh
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20200626130727

FACILITY NAME:LOVE AND COMFORT ELDERLY CAREFACILITY NUMBER:
342700731
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:6532 RANCHO GRANDE WAYTELEPHONE:
(916) 594-9378
CITY:SACRAMNETOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: DATE:
02/16/2021
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Ratu VunimatanaTIME COMPLETED:
09:17 AM
ALLEGATION(S):
1
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3
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Facility staff failed to transport resident to doctor appointments.
INVESTIGATION FINDINGS:
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Based on records reviewed and interviewed, the Department learned that R1’s responsible party (RP) is responsible for all R1’s doctor appointments. RP confirmed to LPA that R1 has not miss many of her doctor’s appointment.
Due to the information gathered LPA finds allegation to be UNFOUNDED. The allegation is 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.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted with Ratu Vunimatana via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tuyet-Suong TehTELEPHONE: (916) 709-6803
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5