342701059-9-7-2022-27-AS-KHOS-CJ8MGV-20220913093633

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701059
Report Date: 09/07/2022
Date Signed: 09/07/2022 10:07:24 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/01/2022 and conducted by Evaluator Victoria Brown

COMPLAINT CONTROL NUMBER: 27-AS-20220901144758

FACILITY NAME:	AMAZING GRACE ELDER CARE #2		FACILITY NUMBER:	342701059
ADMINISTRATOR:	MATIAS, PATRICIA		FACILITY TYPE:	740
ADDRESS:	7723 EL RITO WAY		TELEPHONE:	(916) 329-8745
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95831
CAPACITY:	6	CENSUS: 6	DATE:	09/07/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Patricia Matias		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Facility has an infestation of insects and rodents
Facility failed provide a safe and comfortable environment for residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst Victoria Brown arrived unannounced on 9/7/22 at 8:30am to conduct an investigation of the above mentioned allegations. LPA met with Patricia Matias and stated the purpose of the visit. LPA conducted a tour of the home, interviewed Administrator, Staff 1, 3 residents present in the home and 2 neighbors during this visit.
LPA observed the Licensee is using rock salt and a white powder around the rim of the home to combat the fleas as well as having a pest control come out on 7/9/22. The next door neighbors have a dog so it is unclear where the possible fleas are coming. LPA did not observe bedbugs in the residents room. Based on observations and interviews the facility is not found at fault for the allegations mentioned above. A finding that the complaint 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.
Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was conducted, and a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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