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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700929
Report Date: 03/02/2023
Date Signed: 03/02/2023 05:09:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
01/09/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20230109102835
FACILITY NAME:ALL SEASONS HIALEAHFACILITY NUMBER:
342700929
ADMINISTRATOR:TOLY MOLITVENIKFACILITY TYPE:
740
ADDRESS:8407 HIALEAH WAYTELEPHONE:
(916) 776-6665
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Hayle Zarate, House ManagerTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Staff did not notify resident's authorized representatives of emergency
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with House Manager, Hayle Zarate, to deliver findings in the complaint allegation listed above. LPA wore a surgical mask.

During the investigation, LPA conducted interviews and reviewed documentation pertinant to the investigation.

The results of the investigation are as follows:

Allegation: Staff did not notify resident's authorized representatives of emergency

** Report continued on 9099-C **
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
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 5
Control Number 25-AS-20230109102835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: ALL SEASONS HIALEAH
FACILITY NUMBER: 342700929
VISIT DATE: 03/02/2023
NARRATIVE
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Interviews with relevant parties indicated that facility did not report power outage to families of residents in a timely manner.

LPA reviewed Unusual Incident Report (SIR) submitted to the Department on 1/12/2023 regarding a power outage that occurred at the facility on 1/8/2023. LPA observed that SIR did not indicate whether the families of the residents were notified regarding the power outage.

Based on interviews conducted by the department and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegations are found to be SUBSTANTIATED. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D page.

Exit interview was conducted with House Manager. A copy of this report and appeal rights were provided. House Manager's signature on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20230109102835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: ALL SEASONS HIALEAH
FACILITY NUMBER: 342700929
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/17/2023
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (...) (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by:
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Facility will complete a statement of understanding regarding regulation 87211. Facility will submit statement of understanding to LPA by POC due date of 3/17/2023.
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Based on records reviewed, the facility did not ensure that it was documented that a written report was provided to the families of the residents within seven days of a power outage, which poses a potential health, safety, and personal rights 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 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
01/09/2023 and conducted by Evaluator Michael Hood
COMPLAINT CONTROL NUMBER: 25-AS-20230109102835

FACILITY NAME:ALL SEASONS HIALEAHFACILITY NUMBER:
342700929
ADMINISTRATOR:TOLY MOLITVENIKFACILITY TYPE:
740
ADDRESS:8407 HIALEAH WAYTELEPHONE:
(916) 776-6665
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
03/02/2023
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Hayle Zarate, House ManagerTIME COMPLETED:
05:25 PM
ALLEGATION(S):
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Staff did not follow facility's Emergency Disaster Plan
Staff did not have emergency supplies
Staff did not have provisions for emergency power
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with House Manager, Hayle Zarate, to deliver findings in the complaint allegation listed above. LPA wore a surgical mask.

During the investigation, LPA conducted interviews and reviewed documentation pertinant to the investigation.

The results of the investigation are as follows:

** Report continued on 9099-C **
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
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
Control Number 25-AS-20230109102835
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833
FACILITY NAME: ALL SEASONS HIALEAH
FACILITY NUMBER: 342700929
VISIT DATE: 03/02/2023
NARRATIVE
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Interviews conducted with staff members S1, S2, and S3, resident R1, and relevant party indicated that they were at the facility during a power outage that occurred on 1/8/2023. Interviews with the individuals listed above indicated that the facility had sufficient lighting during the power outage. Interviews conducted with the individuals listed above indicated that the facility had meals prepared for breakfast, lunch, and dinner for the residents. Interviews conducted with the individuals listed above indicated that the facility had a phone available for emergency use if needed. Interviews conducted with the individuals listed above indicated that the residents were not uncomfortable during the power outage.

Interview with staff member S1 indicated that the temperatures were monitored during the night the power outage occurred and reported temperatures ranging from 80 degrees F to 74 degrees F. Interviews with S2, S3, R1, and relevant party did not indicate temperatures at the facility to be too cold for residents during the power outage.

LPA reviewed Emergency Disaster Plan LIC 610E and observed plan to be sufficient in relation to Title 22 regulations.

Based on interviews conducted and observations, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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.

Exit interview was conducted with House Manager and a copy of this report was provided to the facility. The signature of the House Manager on these forms acknowledges receipt of these documents.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Michael HoodTELEPHONE: (916) 531-7341
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5