342701059-4-29-2025-27-AS-CACL-DG9RTQ-20250501131844

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701059
Report Date: 04/11/2025
Date Signed: 04/29/2025 01:04:58 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
02/19/2025 and conducted by Evaluator Kevin Gould

COMPLAINT CONTROL NUMBER: 27-AS-20250219115840

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:	04/11/2025
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rino De La Cruz		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Licensee is in financial distress.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Amazing Grace Elderly Care #2 RCFE on 4/11/25 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Rino De La Cruz and together discussed the investigation details.

Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA requested several months of banking records which did indicate the facility did have sufficient funds to maintain the facility. LPA also requested several months of utility records which did indicate the licensee is paying all required bills in a timely manner and all bills showed a zero balance at each billing cycle.

Report Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025

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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Control Number 27-AS-20250219115840

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: AMAZING GRACE ELDER CARE #2	FACILITY NUMBER: 342701059
	VISIT DATE: 04/11/2025

NARRATIVE

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LPA inspected the facility food supply and observed the food supply to meet the population served. LPA conducted interviews with one staff member who provided statements there was only one delay in payroll but he was paid in full and was just an issue from the licensee being out of town and a holiday weekend. Staff interviewed denied that this is a recurring issue at this facility. LPA interviewed one resident who provided statements to LPA that they like the food at the facility and there are always plenty of food available at the facility.

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 financial issues are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed.

There are no deficiencies is cited per California Code of Regulations, TITLE 22.

Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Kevin Gould	TELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025

LIC9099 (FAS) - (06/04)

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