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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700853
Report Date: 12/27/2023
Date Signed: 12/27/2023 12:11:20 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
12/21/2023 and conducted by Evaluator Victoria Brown
COMPLAINT CONTROL NUMBER: 27-AS-20231221141639
FACILITY NAME:ASTORIA VISTAFACILITY NUMBER:
342700853
ADMINISTRATOR:SILAPA,MONALISAFACILITY TYPE:
740
ADDRESS:8616 BANFF VISTA DRIVETELEPHONE:
(916) 714-4897
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY:6CENSUS: 6DATE:
12/27/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Monalisa SilapaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility staff did not ensure that resident's bed was free of roaches.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegation on 12/27/23 at 9am. LPA was met by Caregiver Jezler Flores and stated the purpose of the visit. Caregiver contacted Administrator Monalisa Silapa regarding todays visit. LPA conducted a physical plant tour of the resident(s) rooms and observed chest of drawers. Administrator arrived within 15 minutes to assist with todays visit. LPA conducted interviews of resident #1 (R2-R6), staff #1 (S1-S2), and Administrator. Administrator contacted The Noble Way Pest Control to confirm the start date of pest control services. The start date was 5/25/2022 and the last service was conducted on 11/13/23, the next visit is planned for January 2024. LPA received a copy of the service invoice for 6/9/23 and 11/13/23 as confirmation that the service(s) occurred. It indicates that interior physical plant cobwebs were removed and the exterior physical plant was treated for general pests. The last interior service was conducted on 6/9/23. LPA observed all rooms and drawers and found 1 chest of drawer in R1's room with roach droppings.
See 9099C for continuation...
Substantiated
Estimated Days of Completion: 30
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
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-20231221141639
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: ASTORIA VISTA
FACILITY NUMBER: 342700853
VISIT DATE: 12/27/2023
NARRATIVE
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9099 Continued...

R2-R6 all concur that roaches/bugs/insects have not been observed in their rooms nor in the facility. S1-S2 concur that a roach was observed when R1 had a visitor.

Based on observation by LPA and Administrator, and interviews conducted confirmed during this visit, the investigation revealed that the facility has a contract with a pest control. The facility is not infested and this may have been an isolated occurrence. However, the most recent service did not entail spraying for pests
for interior physical plant which was conducted 6 months ago.

The preponderance of evidence has been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 9099D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The facility representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of the report was given.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20231221141639
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: ASTORIA VISTA
FACILITY NUMBER: 342700853
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87303(a)
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Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee/Administrator shall request an additional service to include the interior of the facility. Confirmation of service date in addition to the scheduled date for January shall be faxed to Community Care Licensing by POC due date.
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This requirement is not met as evidenced by: Based on Interviews and LPA observation with Administrator, roach droppings in R1's chest of drawers. This violation poses a potential 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.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3