342701151-10-1-2024-27-AS-KHOS-DA4K4D-20241016073409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701151
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:22:26 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
07/17/2024 and conducted by Evaluator Tung Truong

COMPLAINT CONTROL NUMBER: 27-AS-20240717083011

FACILITY NAME:	AGCAOILI RESIDENTIAL CARE HOME		FACILITY NUMBER:	342701151
ADMINISTRATOR:	AGCAOILI JR., RUSTICO		FACILITY TYPE:	735
ADDRESS:	8042 BROUILLY COURT		TELEPHONE:	(916) 829-5054
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95829
CAPACITY:	4	CENSUS: 3	DATE:	10/01/2024
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Rustico Agcaoili Jr.		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Due to lack of supervision, resident is leaving the facility unassisted

INVESTIGATION FINDINGS:

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On 10/1/24, Licensing Program Analyst (LPA) Tung Truong arrived unannounced to conclude the investigation of the above allegation and to deliver the findings. LPA met with Administrator Rustico Agcaoili Jr. and explained the purpose of the visit.

Throughout the course of the investigation, LPA Truong conducted interviews and reviewed records. Based on interviews and record reviews, there is insufficient evidence to substantiate the allegation mentioned above. Based on statements obtained, there is no indication that resident (R1) eloped from the facility unassisted due to lack of supervision. Based on staff interviews, staff stated that R1 was supervised, but they cannot stop R1 from jumping over the fence and run away. Residents and staff who were interviewed corroborated that R1 has exit seeking and aggressive behavior. Residents who were interviewed stated that they feel safe and have no concerns with care.

Based on information obtained, LPA finds the allegation above to be UNSUBSTANTIATED- 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.

Exit interview was conducted and a copy of the report was provided upon exit.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Tung Truong
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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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