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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700758
Report Date: 10/06/2023
Date Signed: 10/06/2023 03:25:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH 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
08/14/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230814135530
FACILITY NAME:LOVE AND COMFORT IIFACILITY NUMBER:
342700758
ADMINISTRATOR:VUNIMATANA, RATUFACILITY TYPE:
740
ADDRESS:320 BOWMAN AVETELEPHONE:
(916) 832-3626
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY:6CENSUS: 6DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Eliesa QioleleTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Facility allowed excluded person to facilitate operations
Administrator is not present
INVESTIGATION FINDINGS:
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On 10/06/2023 at 2:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care staff, Eliesa Qiolele and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 6 with two facility staff. A telephone call was made to administer to read the complaint findings since administrator was not present during today visit.

Allegation: Facility allowed excluded person to facilitate operations
It was alleged that the facility allowed an excluded person to facilitate operations. This investigation consisted of records reviewed and interviews with staff, residents, residents’ responsible parties, an excluded individual (E1) and outside agency. During the investigation, LPA Lee learned (E1) is a facility administrator and was in the facility in March 2023 to check on the facility. It was learned that on 07/11/2022 at 6:25 PM, (E1) contact number was given to (RP1) in regards to (R2) payment and charges. It was also learned that on 08/01/2023 at 19:27, (E1) communicated with an outside agency (OA1) regarding a client at the facility. (E1) stated via text messages that (E1) "spoke with our team" and "we would like to move forward with the plan of relocating resident 1 (R1).” (E1) asked (OA1) to call Abounding Peace Elderly Care II's administrator, Una Waqalala. Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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 3
Control Number 27-AS-20230814135530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: LOVE AND COMFORT II
FACILITY NUMBER: 342700758
VISIT DATE: 10/06/2023
NARRATIVE
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 It was also learned that on 09/06/2023 resident responsible party (RP1) received a phone call from administrator, Ratu Vunimatana stating administrator was going to put (RP1) on a three-way call with (E1) regarding payment that was owed for (R2.) On 09/28/2023, it was learned (OA2) stated that (OA2) have spoken to (E1) regarding (R1) and that’s how (R1) got placed at Love and comfort II. During today’s visit it was learned from administrator that administrator did call (E1) to assist with finding a new placement for (R1). The licensee was aware that (E1) was excluded since licensee also received a copy of the stipulation order and still knowingly allows, person in the facility and facilitate operations in regarding to residents.
The department has determined the following as it relates to the allegations that the facility allowed an excluded person to facilitate operations: Based on interviews and recorded review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.

Allegation: Administrator is not present

It was alleged that the facility administrator is not present in the facility. This investigation consisted of records reviewed and interviews with staff, residents, and outside agency. Interviews revealed that the administrator is not in the facility often and that administrator is at the facility three times a week and when administrator is present in the facility administrator doesn’t stay long in the facility. 3 out 3 residents stated that resident doesn’t not see administrator in the facility as well. On 09/28/2023, it was learned that an outside agency (OA1) who comes to the facility to support a resident about once or twice a week shared that (OA1) only see administrator about 4-5 times per month.

Furthermore, on 08/24/2023 a telephone call and email to administrator confirmed with LPA Lee that the facility LIC 500 Personnel Report, administrator’s scheduled day and time at the facility is as follows: Monday, Tuesday, Wednesday, Thursday, and Friday from 8:00 AM to 3:00 PM. During the complaint visit LPA Lee visited the facility on 08/21/2023 from 11:15 AM to 3:15 PM, 08/24/2023 from 1:10 PM to 2:05, 08/29/2023 from 9:40 AM to 10:30 AM, and 09/28/2023 from 12:58 PM to 2:30 PM and LPA Lee did not observed administrator present at the facility per LIC 500 Personal Report.

The department has determined the following as it relates to the allegations that the facility administrator is not present: Based on observations, interviews and recorded review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met.



This facility is cited per 22 CCR Section 87355(e)(1). An immediate civil penalty in the amount of $100 per day for one day, for a total of $100, was assessed. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the 9099 report, 9099-D page, and appeals right document were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20230814135530
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: LOVE AND COMFORT II
FACILITY NUMBER: 342700758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/13/2023
Section Cited
CCR
87255(e)(1)
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87355(e)(1) Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section. (1) Obtain a California clearance or a criminal record exemption as required by the Department...

This requirement is not met as evidenced by:
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The licensee agrees to read regulation 87355(e)(1) and submit a signed declaration of understanding to LPA Lee by POC due date of 10/13/2023 by 5:00 PM end of day.
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Based on interviews and records review, licensee did not comply with the section cited above. The licensee allowed an excluded individual to facilitate operations regarding residents, which poses/posed a potential health, safety, or personal rights risk to persons in care.
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Type B
10/13/2023
Section Cited
CCR
87405(a)
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87405(a) Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours…

This requirement is not met as evidenced by:
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Administrator agrees to read regulation 87405(a) and submit a signed declaration of understanding. The administrator will review LIC 500 Personnel Report for accuracy and ensure the administrator is present at the facility for a sufficient number of hours.
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Based on interviews, records review and observations, the licensee did not comply with the section cited above. The licensee did not ensure that administrator is at the facility for sufficient number of hours, which poses/posed a potential health, safety or personal rights to person in care.
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The administrator will email POC to LPA Lee by POC due date 10/13/2023 by 5:00 PM end of day.
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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3