342701143-6-15-2023-27-AS-KHOS-CTMNRH-20230711104133

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701143
Report Date: 06/15/2023
Date Signed: 06/15/2023 09:01:00 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
10/07/2022 and conducted by Evaluator Renee Campbell

COMPLAINT CONTROL NUMBER: 27-AS-20221007164831

FACILITY NAME:	GROVE ST CARE HOME, LLC		FACILITY NUMBER:	342701143
ADMINISTRATOR:	SANDOVAL, MANUEL ALBERTO		FACILITY TYPE:	740
ADDRESS:	9189 GROVE ST.		TELEPHONE:	(916) 686-2859
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95624
CAPACITY:	6	CENSUS: 2	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Manuel Sandoval, Licensee		TIME COMPLETED:	09:15 AM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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On 06/15/2023, Licensing Program Analyst Renee Campbell arrived at Grove St. Care home to deliver findings for complaint 27-AS-20221007164831. LPA met with Manuel Sandoval, Licensee, and explained the purpose of the visit. The investigation was conducted by the Department which consisted of a review of records and interviews.

There were no direct witnesses or evidence to corrobate R1’s claim that a man punched her neck. Interviews revealed R1 was diagnosed with dementia and experienced hallucinations. Per physician, R1 injuries could have been from traumas such as a fall or automobile accident and cannot specifically determine how R1 sustained the injuries. At this time the coroner’s report is still pending and the RO is waiting to receive R1 death certificate.

As a result of this investigation. The Department finds the allegation unsubstantiated. Although the allegation may have happened, is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Emerita Curiel	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Renee Campbell	TELEPHONE: 916-206-6380
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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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