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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701031
Report Date: 04/25/2022
Date Signed: 04/25/2022 10:30:53 AM

Document Has Been Signed on 04/25/2022 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:J. NAGTALON ADULT CARE SERVICES IIFACILITY NUMBER:
342701031
ADMINISTRATOR:WANDASAN, JUDITHFACILITY TYPE:
735
ADDRESS:8155 SAINT BRENDAN PLACETELEPHONE:
(916) 524-2717
CITY:SACRAMENTOSTATE: CAZIP CODE:
95829
CAPACITY: 4CENSUS: 4DATE:
04/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Susan NagtalonTIME COMPLETED:
10:30 AM
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On 04/25/2022, Licensing Program Analyst (LPA) Chris Hopkins, conducted an unannounced case management visit regarding an incident report which occurred on 04/15/2022. LPA met with Licensee Susan Nagtalon and explained the purpose of the visit.

LPA Hopkins reviewed the incident report submitted to CCLD on 04/18/2022 regarding an incident that happened on 4/15/2022. Resident 1 (R1) accused staff 1 (S1) of physically hitting him/her. R1 called 911 and Police arrived on scene. During the interview R1 changed his story on what staff hit him/her and accused staff 2 (S2) of hitting him/her. Licensee conducted investigation along with Administrator and found that R1 was not physically hit. Licensee interviewed staff and both S1 and S2 denied hitting R1. Licensee examined R1 for any marks or signs of being hit and there were none. LPA interviewed R1 and R1 stated that S2 did not hit him/her, it was S1 that him/her. LPA then asked where did S1 hit him/her, and R1 responded he/she did not know. LPA interviewed S1 and S1 denied ever hitting R1.

No deficiencies cited during visit.

Exit interview conducted with Licensee and a copy of report given.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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