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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700807
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:00:54 PM

Unsubstantiated


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
05/01/2024 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20240501090629
FACILITY NAME:AGAPE SUPPORTED HOMESFACILITY NUMBER:
342700807
ADMINISTRATOR:OMORAGBON, OSCARFACILITY TYPE:
735
ADDRESS:3120 MOUNTAIN VIEW DRIVETELEPHONE:
(916) 993-8433
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:4CENSUS: 4DATE:
08/02/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Janet EgberuareTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff leaves resident soiled resulting in resident sustaining a diaper rash.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to the Agape Supported Homes ARF on 8/2/24 at 12:45pm to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator and together discussed the investigation details.

Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because all staff members interviewed denied the allegations. LPA conducted two staff interviews who both denied the allegations and provided contestant statements to LPA regarding brief use for R1. LPA determined that R1 did have a rash that was communicated with authorized representatives, physician and was being addressed with medication by facility staff prior to the complaint being received. LPA could not conduct a substantive interview with R1.

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
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-20240501090629
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: AGAPE SUPPORTED HOMES
FACILITY NUMBER: 342700807
VISIT DATE: 08/02/2024
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of neglect/lack of supervision are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2