342701155-4-20-2023-27-AS-KHOS-CR8HY8-20230425063619

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701155
Report Date: 04/19/2023
Date Signed: 04/20/2023 02:21:14 PM

Substantiated

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
02/27/2023 and conducted by Evaluator Vincent Moleski

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230227145151

FACILITY NAME:	MILESTONE CAREHOME INC		FACILITY NUMBER:	342701155
ADMINISTRATOR:	MERCADO, JENNIFER		FACILITY TYPE:	735
ADDRESS:	9001 GENERATIONS DR		TELEPHONE:	(916) 478-0478
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95758
CAPACITY:	4	CENSUS: 2	DATE:	04/19/2023
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Jennifer Mercado		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Knives are accesible to resident in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPAs) Vincent Moleski and Jason Lund arrived unannounced to deliver findings on this complaint investigation. LPAs Moleski and Lund met with administrator Jennifer Mercado and explained the purpose of the visit.

This complaint was investigated by LPAs Moleski and Lund. The investigation consisted of one staff interview (S1), two resident interviews (R1 and R2), an interview with administrator Mercado, record review of R1’s resident records, including an IPP, SIRs, and intervention plans, record review of R2’s resident records, and observation of the facility’s kitchen, living room and dining area.

An SIR reviewed by LPAs Moleski and Lund indicated that on February 26, 2023, R1 acquired a knife while S1 was preparing food in the kitchen. According to the SIR, S1 was slicing fruit in the kitchen, but put the knife down on the countertop to retrieve more fruit from the refrigerator. [Continued on 9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 27-AS-20230227145151

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MILESTONE CAREHOME INC	FACILITY NUMBER: 342701155
	VISIT DATE: 04/19/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

At this point, R1 came into the kitchen from the living room and grabbed the knife, according to the SIR. Administrator Mercado corroborated this narrative during an interview.

R1’s IPP indicated that R1 has limited safety awareness, and that family members had previously expressed concerns regarding R1’s ability to handle knives safely.

During an interview, S1 said that on February 26, 2023, they set a knife down on the counter, and turned their back to R1 while R1 was in the living room in order to look for more fruit in the refrigerator.

The department has determined the following as it relates to the allegation that knives are accessible to resident in care:

Based on record review of R1's IPP and SIRs, and based on interviews with administrator Mercado and S1, a knife was accessible to a resident on February 26, 2023, and, therefore, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is being cited per 22 CCR Section 80087(g).

An exit interview was held with Mercado. A copy of this report and appeal rights were left with Mercado.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230227145151

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: MILESTONE CAREHOME INC	FACILITY NUMBER: 342701155
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/20/2023 Section Cited CCR 80087(g)	1 2 3 4 5 6 7	“Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.” This was not met based on LPA record review and interviews.	1 2 3 4 5 6 7	Administrator will conduct a staff training regarding knife safety.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Vincent Moleski
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3